Office or other outpatient visit, new patient, level 4
Audit Defense & Denial Intelligence
Research-based denial patterns from OrbDoc Bill Analyzer
1. Insufficient moderate complexity documentation for new patient
CommonNew patient moderate complexity visits (45-59 minutes or moderate MDM) are frequently billed but require substantial documentation of multiple problems, diagnostic workup, or moderate risk.
Common Causes
- • Single problem without complexity elements
- • Time falls below 45-minute threshold
- • MDM doesn't demonstrate moderate complexity (need 2 of 3 elements)
Resolution Strategy
Demonstrate moderate MDM with documentation of: moderate number of problems, moderate data reviewed, or moderate risk. Or document 45-59 minutes total time.
💬 Plain Language Explanation
What this means
This is a new patient office visit with a high level of complexity. Your doctor performed a comprehensive examination and made complex medical decisions.
Why you might see this
This code is used when you're seeing a doctor for the first time (or haven't seen them in 3+ years) and your visit required extensive evaluation, multiple concerns, or complex treatment planning.
Common context
Used for new patients with complex medical issues, multiple concerns, or extensive evaluation needs.
What to ask your provider
"'As a new patient, what made this visit so complex that it required this level of service?'"
Relative Value Units (RVUs)
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Clinical Information
When to Use
New patient visit with moderate complexity medical decision-making or 45-59 minutes total time
Common Scenarios
Documentation Requirements
- Comprehensive history including detailed ROS and PFSH
- Comprehensive examination (8+ organ systems)
- Moderate complexity medical decision-making
- OR document 45-59 minutes total time with activities
Coding Guidelines
Common Modifiers
Bundling Rules
- Requires comprehensive documentation for new patient
Exclusions
- Do not use for established patients (use 99214)
- Do not use if time <45 minutes (use 99203)
- Do not use if time ≥60 minutes (use 99205)
Coding Notes
Clinical scenarios
- Comprehensive history including detailed ROS and PFSH
- Comprehensive examination (8+ organ systems)
- Moderate complexity medical decision-making
- Comprehensive history including detailed ROS and PFSH
- Comprehensive examination (8+ organ systems)
- Moderate complexity medical decision-making
- Comprehensive history including detailed ROS and PFSH
- Comprehensive examination (8+ organ systems)
- Moderate complexity medical decision-making
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Code Details
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PFSRVU Breakdown
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Frequently Asked Questions
CPT 99204 is the billing code for "Office or other outpatient visit, new patient, level 4". New patient visit with moderate complexity medical decision-making or 45-59 minutes total time
Medicare pays approximately $163.35 for CPT 99204 (national average). Actual payment varies by geographic location due to GPCI adjustments. Hospital and commercial insurance rates are typically 2-4x higher than Medicare rates.
CPT 99204 has a total RVU of 4.78, broken down as: Work RVU 2.60, Practice Expense RVU 2.00, and Malpractice RVU 0.18. RVUs (Relative Value Units) determine Medicare reimbursement rates.
The most common denial reason for CPT 99204 is "Insufficient moderate complexity documentation for new patient". New patient moderate complexity visits (45-59 minutes or moderate MDM) are frequently billed but require substantial documentation of multiple problems, diagnostic workup, or moderate risk. Common causes include: Single problem without complexity elements; Time falls below 45-minute threshold. Appeal success rate is approximately 40-60%.
Key documentation requirements for CPT 99204 include: Comprehensive history including detailed ROS and PFSH; Comprehensive examination (8+ organ systems); Moderate complexity medical decision-making; OR document 45-59 minutes total time with activities. Missing or incomplete documentation is a leading cause of claim denials for this code.
Bundling considerations for CPT 99204: Requires comprehensive documentation for new patient. Use an NCCI bundling checker to verify specific code combinations before billing.
Common modifiers for CPT 99204 include: 25 (When E/M separate from same-day procedure). Modifiers indicate special circumstances and can affect reimbursement or prevent claim denials.
The typical time requirement for CPT 99204 is 45-59 minutes total time on date of service. Time-based codes require documentation of the actual time spent providing the service.