CPT Code 99204: Billing Guide & Reimbursement Rates [2022]

In our guide to CPT Code 99204, we’ll teach you about this straightforward complexity evaluation and management procedure code, 99204 guidelines for billing, and the CPT Code 92204 reimbursement rate for Medicare in 2022.

cpt code 99204

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CPT Code 99204 Definition

cpt code 99204 reimbursement rate

99204 Description:  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 medical decision making.

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CPT Code 99204 Reimbursement Rate (Medicare, 2022): $185.26

In the past years, this E/m code has been paid $169.93 by Medicare in 2021.
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CPT Code 99204 Time Length: 45 – 59 Minutes

cpt code 99204 description

An average session length for an initial 99204 evaluation and management session is around 50 minutes.

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99204 Billing Guidelines:

Using CPT code 99204 requires a medical decision making level of moderate with a medically appropriate history or examination.

CPT CodeMedical Decision MakingTime LengthReimbursement Rate (2022)
99202Straightforward15 - 29 Minutes$80.91
99203Low30 - 44 Minutes$124.39
99204Moderate45 - 59 Minutes$185.26
99204High60 - 74 Minutes$244.99

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“In 2021, new patient codes 99202-99205 no longer require the three key components or reference typical face-to-face time. Instead, each service includes “a medically appropriate history and/or examination,” and code selection is based on the MDM [medical decision making] level or total time spent on that date.”

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This decision was made on 1/1/2021 to update the descriptor for Group 1 CPT and HCPCS codes 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, and 99215.

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Pick the code that is based on the length of service and complexity of medical decision making and appropriate level of care required.

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99204 Requirements:

  • Medical decision making: moderate
  • Time length: 45 – 59 Minutes
  • Evaluation of clinical history and examinations

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