Code 99204 represents a new patient appointment that’s at least 45 minutes in duration.
October 24, 2024
11 min read
The 99204 code is an E/M code used by prescribing providers. For other E/M codes, visit this overview.
Code 99204 represents a new patient appointment that’s at least 45 minutes in duration. It’s a prescriber code, which means it’s most commonly used by psychiatrists or nurse practitioners.
This is is how the American Medical Association defines 99204 in the official CPT codebook:
CPT code 99204: New patient office visit, minimum 45 minutes
Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded.
As a prescriber, you can bill insurance according to time or medical decision-making (MDM). Make sure to include sufficient documentation to support the method you choose.
If you spent at least 45 minutes with a client but the case was especially complex or high risk, or involved reviewing or analyzing a lot of data, you may use a higher CPT code, including 99205 (high MDM).
It’s important to use the code that most accurately reflects the time you spent with the patient to treat their condition, and ensure that documentation for the session supports the chosen code.
Simplify insurance and save time on your entire workflow — from compliance and billing to credentialing and admin.
If you’re treating an existing patient, you should use 99214 instead. A new patient is someone you have not seen in the last three years.
Documentation for 99204 is essentially the same as other E/M codes, but geared toward a new patient.
Here’s a new patient example note:
Patient Name: Rose Jackson
Date of Service: 03/27/2023
Patient DOB: 3/30/1997
Appointment Time: 2:30pm-3:15pm
Place of Service: Patient was located at their home at 123 Main St Anywhere US 12345
Provider was located at their office: 456 Storybook Ln Hollywood CA 96852
This session was provided via a HIPAA compliant interactive audio/video platform. The patient consented to this telemedicine encounter.
The total time I spent caring for this patient today was 55 minutes which included: interviewing the client, documenting, reviewing the patient's responses to questionnaires, discussing treatment plans, coordinating care, prescription management and counseling the client on managing her mental health.
Chief Complaint: Patient presents with anxiety and panic attacks, occurring 3-4 times per week.
HPI: 27-year-old female reports experiencing uncontrolled anxiety and recurrent panic attacks for the past 4 months. She describes palpitations, shortness of breath, and chest tightness during these episodes. Patient also reports difficulty concentrating and frequent crying spells. Denies any suicidal ideation.
ROS:
PMH/PSH:
Medications: None currently.
Allergies: No known drug allergies.
Substance Use Assessment: Denies tobacco and drug use, occasional alcohol use (1-2 drinks per week).
MSE:
PDMP Check: The state’s PDMP was reviewed as required, and no concerning patterns were identified.
Risks and Benefits of Medication Adherence: The patient was counseled on the risks and benefits of adhering to prescribed medications, including potential side effects and the importance of consistent use for efficacy.
Time spent: 45 minutes face-to-face.
Electronically signed by:
[Provider name, Credentials, Date signed]
_____________________________________________________________________________________________
Rationale information is not required in your note; it is provided for educational purposes only.
Number and Complexity of Problems Addressed: Moderate, 1 chronic illness with exacerbation
Data Reviewed/Analyzed: none
Risk: Moderate: Moderate, prescription drug management
Rationale: The client displays Moderate number & complexity of problems with one chronic illness with an exacerbation, No data reviewed, and Moderate risk for no prescription management.
Level of MDM: Moderate
CPT Codes Selected: 99204
Reimbursement rates for sessions billed with 99204 will vary depending on factors like the specific payer contract, your geographic location, and type of therapy license. Headway providers can check the portal for rates with each insurance provider.
This document is intended for educational purposes only. It is designed to facilitate compliance with payer requirements and applicable law, but please note that the applicable laws and requirements vary from payer to payer and state to state. Please check with your legal counsel or state licensing board for specific requirements.
Simplify insurance and save time on your entire workflow — from compliance and billing to credentialing and admin.
This content is for general informational and educational purposes only and does not constitute clinical, legal, financial, or professional advice. All decisions should be made at the discretion of the individual or organization, in consultation with qualified clinical, legal, or other appropriate professionals.
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Understand the ins and outs of CPT codes to help make documentation and billing more efficient — and give you more time to focus on other areas of your practice.
Headway strives to simplify billing insurance so you can focus on providing care. Read our comprehensive guide to mental health billing.
Understand the ins and outs of CPT codes to help make documentation and billing more efficient — and give you more time to focus on other areas of your practice.
