CPT Code 99204: New Patient, Moderate MDM

• CPT Codes
• 99204

CPT Code 99204: New Patient, Moderate MDM

CPT code 99204 for new patient visits with moderate complexity MDM. Reimbursement rates, documentation, and psychiatric evaluation guidance.

Quick Reference

Code

99204

Code System

CPT

Category

CPT Codes

Published

Mar 4, 2026

Reading Time

9 min

CPT® is a registered trademark of the American Medical Association. All CPT code descriptions on this page are paraphrased in original wording; consult the current CPT® codebook published by the AMA for authoritative descriptors.

Understanding CPT Code 99204: New Patient Office Visit

CPT code 99204 describes an office or other outpatient visit for the evaluation and management of a new patient requiring moderate complexity medical decision making. With a typical time of 45-59 minutes, this code is one of the most frequently billed new patient E&M codes in behavioral health, particularly for initial psychiatric evaluations, comprehensive intake assessments, and new patient encounters involving multiple clinical concerns.

Definition and Purpose

CPT 99204 belongs to the office/outpatient E&M code series (99202-99215) and represents the second-highest level of new patient visit complexity. Under current E&M guidelines, code selection is based on either the level of medical decision making or total time spent on the encounter date.

For 99204, moderate complexity medical decision making requires meeting at least two of the following three elements:

Alternatively, providers may select 99204 based on total time of 45-59 minutes spent on the date of the encounter. This time encompasses all provider activities related to the encounter, whether or not the patient is present.

• Number and complexity of problems: One or more chronic illnesses with mild exacerbation, progression, or side effects of treatment; or two or more stable chronic illnesses; or one undiagnosed new problem with uncertain prognosis; or one acute, uncomplicated illness or injury
• Amount and complexity of data: Moderate category of data to be reviewed and analyzed, such as ordering and reviewing tests, obtaining history from someone other than the patient, independent review of an image or test, or discussion of management with an external physician
• Risk of complications: Moderate risk of morbidity from additional diagnostic testing or treatment, such as prescription drug management, decision about minor surgery with identified risk factors, or decisions regarding elective major surgery without identified risk factors

When to Use 99204 in Behavioral Health

CPT 99204 is a workhorse code in behavioral health settings. It fits a wide range of new patient encounters that go beyond simple evaluations but do not reach the level of high complexity. Common behavioral health use cases include:

• Initial psychiatric evaluations where the provider assesses a new patient with a mood, anxiety, or psychotic disorder, reviews previous treatment history and medications, and develops a comprehensive treatment plan
• Comprehensive substance use disorder assessments for new patients presenting with alcohol or drug use disorders, particularly when the evaluation includes reviewing prior treatment episodes, assessing co-occurring mental health conditions, and determining the appropriate level of care
• Intake evaluations for residential or PHP programs where the provider must assess medical stability, review multiple records from referring providers, and coordinate with the treatment team on initial care planning
• New patient evaluations involving medication management where the provider considers initiating psychotropic medications, reviews drug interactions, and assesses risk factors for adverse effects
• Dual diagnosis assessments where a new patient presents with co-occurring mental health and substance use conditions requiring evaluation of both areas
• Complex referral evaluations where the provider reviews substantial outside records, communicates with referring providers, and formulates a differential diagnosis

99204 vs. Psychiatric Diagnostic Evaluation Codes

A common question in behavioral health billing is whether to use 99204 or the psychiatric diagnostic evaluation codes (90791/90792). Here are the key distinctions:

Choose 99204 when the encounter follows the traditional E&M structure with MDM or time-based documentation. Choose 90791/90792 when the encounter is structured as a diagnostic psychiatric evaluation with standardized components.

Documentation Requirements

To support 99204, the medical record must demonstrate either moderate complexity MDM or 45-59 minutes of total time.

For MDM-based billing, document:

For time-based billing, document:

Behavioral health documentation tips:

• Detailed chief complaint and history of present illness, including onset, duration, severity, and contributing factors
• At least one chronic illness with mild exacerbation or progression, or two or more stable chronic conditions, or an undiagnosed new problem with uncertain prognosis
• Evidence of moderate data review, such as reviewing outside records, ordering and reviewing lab work or screening tools, obtaining collateral history from family members, or discussing management with another provider
• Moderate risk management decisions, such as initiating or adjusting prescription medications, ordering diagnostic studies with potential risks, or making decisions about treatment level of care
• Assessment for each problem addressed, with clinical reasoning
• Treatment plan that aligns with the documented complexity

• Statement that total time is the basis for code selection
• Total time spent on the date of the encounter (45-59 minutes)
• Description of activities performed during that time
• Clinical assessment and plan

• Include results from validated screening instruments (PHQ-9, GAD-7, Columbia Suicide Severity Rating Scale, AUDIT, DAST-10) and document how results informed clinical decision making
• Note all sources of data reviewed: prior treatment records, lab results, collateral contacts, prescription drug monitoring program queries
• Document risk assessment thoroughly, including suicidal ideation, homicidal ideation, self-harm history, and substance use risk
• Record any communication with other providers, treatment team members, or referral sources
• Describe the rationale for treatment decisions, particularly medication selection and level of care determination

Billing and Reimbursement

Step-by-Step Billing Process

• Verify new patient status. Confirm the patient has not received professional services from the provider or a same-specialty provider in the same group within the past three years.
• Select between MDM and time-based billing. For many behavioral health encounters, time-based billing may support a higher code level. Evaluate both methods and select the one that most accurately reflects the encounter.
• Complete documentation. All required elements must be documented before claim submission.
• Assign ICD-10 diagnosis codes. Use codes that accurately reflect all conditions addressed during the encounter and support medical necessity for the billed service.
• Assign place of service. Use POS 11 (office), POS 02 ( telehealth ), POS 52 (psychiatric facility), POS 53 (community mental health center), or the applicable code for your setting.
• Apply modifiers. Append modifier 95 for telehealth, modifier 25 for separately identifiable E&M on the same day as a procedure, or other required modifiers.
• Submit and monitor. Track claim status and respond promptly to any requests for additional documentation.

Reimbursement Rates

As of March 2026, approximate reimbursement rates for CPT 99204 are:

These rates are approximate and subject to annual updates. Always verify current rates with your specific payer contracts.

• Medicare: Approximately $170 (national average; geographic locality adjustments apply)
• Medicaid: Varies by state, generally ranging from $100 to $160
• Commercial payers: Typically 130-170% of Medicare rates depending on the contracted fee schedule

Common Modifiers

The following modifiers are frequently used with CPT 99204:

• Modifier 25 — Significant, separately identifiable E&M service on the same day as a procedure or other service. Common when an initial evaluation includes a separately billable service such as psychological testing administration.
• Modifier 95 — Synchronous telehealth service rendered via real-time interactive audio and video. Required by many payers for telehealth encounters.
• Modifier GT — Via interactive audio and video telecommunications systems. Some payers use GT as an alternative to modifier 95.
• Modifier 52 — Reduced services. Rarely used with E&M codes but may apply if the encounter was interrupted or incomplete.

Modifier Considerations for Behavioral Health

• When performing a new patient E&M visit and a separately billable screening (such as alcohol and substance brief intervention, SBIRT codes), modifier 25 on the E&M code distinguishes the two services.
• For telehealth encounters, verify whether your payer requires modifier 95, GT, or both. Policies vary significantly across payers.
• Avoid using modifier 25 as a routine practice. It should only be appended when a genuinely separate, identifiable service is performed and documented.

Compliance Considerations

Key Compliance Requirements

• Documentation supports code level. The most common compliance issue with 99204 is insufficient documentation to support moderate complexity MDM. Each MDM element must be explicitly documented, not implied.
• Appropriate use of time-based billing. If using time as the basis for code selection, the documented time must reflect actual time spent. Ensure the activities described are eligible for inclusion in total time.
• Medical necessity. The encounter must be medically necessary for the conditions documented. Routine comprehensive evaluations without a clinical indication do not meet medical necessity requirements.
• Distinct from psychiatric evaluation codes. Ensure you are not double-billing for overlapping services. If the encounter is better described by a psychiatric diagnostic evaluation code, bill accordingly.

Common Pitfalls

• Defaulting to 99204 for all new patient intakes. Not every new patient encounter meets moderate complexity MDM. Some intakes are straightforward (99202) or low complexity (99203), while others may warrant high complexity (99205).
• Insufficient data documentation. Simply stating “records reviewed” is not adequate. Document what records were reviewed, from whom they were obtained, and how the information influenced clinical decision making.
• Inadequate risk documentation. Prescription drug management alone may support moderate risk, but the documentation must clearly indicate the provider considered the risks, benefits, and alternatives of the medication.
• Missing problem documentation. For moderate MDM, the documented problems must meet the threshold. One self-limited problem does not qualify; you need at least one chronic condition with exacerbation or equivalent complexity.

Related Billing Codes

• 99201
• 99202
• 99203
• 99205
• 99211
• 99212

Reference tables

Common questions

Official sources

No publisher link is recorded for this topic yet. Confirm the requirement with the governing payer, state agency or accreditor before relying on it — see the primary source directory.