The short version
- 99204 is a level 4 office visit for a new patient. Moderate-complexity medical decision making, or 45 to 59 minutes of total time on the date of service. Either path on its own.
- Moderate MDM means two of three grid elements reach moderate: problems addressed, data reviewed, or risk. Not all three.
- Prescription drug management, by itself, puts the risk column at moderate. That one fact decides a lot of visits that get billed as 99203.
- 2026 Medicare pays about $177 nationally for 99204, non-facility, against a conversion factor of $33.40 for non-QP clinicians and $33.57 for QPs.
- Office visits were exempt from the 2026 efficiency adjustment. The work RVU for 99204 is unchanged at 2.60.
What 99204 actually requires in 2026
History and exam no longer determine the level. You document them as medically appropriate and they carry no scoring weight. What sets the level is medical decision making or total time. The same two paths run through every new patient code, 99202 to 99205.
By MDM, 99204 is moderate complexity. That is a defined bar with a defined grid, and it is the part most practices guess at. The next section walks it.
By time, 99204 is 45 to 59 minutes of total time on the date of service. That includes chart review before the visit, the visit itself, and the note, as long as it all happens that day. It excludes staff time and work done on a different day.
Cross 60 minutes and it is a 99205 on time alone. Stay under 45 and, on the time path, it is a 99203.
Moderate MDM in plain terms
The grid has three columns. Hit moderate in two of them and the visit is a 99204.
Problems addressed. Moderate means one chronic illness with exacerbation, progression, or treatment side effects; or two or more stable chronic illnesses; or one undiagnosed new problem with an uncertain prognosis; or one acute illness with systemic symptoms; or one acute complicated injury.
Data reviewed. Moderate means any one of three things: a combination of three items drawn from reviewing prior external notes, reviewing or ordering unique tests, and taking a history from an independent source; or independently interpreting a test somebody else performed and billed; or discussing management with an external physician or qualified professional.
Risk. Moderate means prescription drug management; or a decision about minor surgery with identified patient or procedure risk factors; or a decision about elective major surgery with no identified risk factors; or a diagnosis or treatment significantly limited by social determinants of health.
That risk column is the one practices forget. Writing or adjusting a prescription is prescription drug management. On its own it sets risk at moderate. Pair it with one undiagnosed new problem, or with three data items, and you have two of three.
What 99204 pays in 2026
Medicare’s 2026 conversion factor is $33.40 for clinicians who are not qualifying APM participants and $33.57 for those who are, both effective January 1, 2026. At 5.31 non-facility RVUs, 99204 lands at about $177 nationally before locality adjustment. In a facility setting the same code pays about $117, which is the practice-expense difference, not a coding difference.
Two things beyond the rate. The 2026 efficiency adjustment cut work RVUs by 2.5% across roughly 7,700 codes and did not touch office visits — CMS exempted the time-based E/M family, 99202 through 99215. The work RVU for 99204 is still 2.60. Separately, indirect practice expense for facility-setting work was cut in half, which moves money toward care delivered in your own office.
| Code | Level | Time (total, date of service) | MDM | 2026 national average |
|---|---|---|---|---|
| 99202 | 2 | 15-29 min | Straightforward | ~$75 |
| 99203 | 3 | 30-44 min | Low | ~$118 |
| 99204 | 4 | 45-59 min | Moderate | ~$177 |
| 99205 | 5 | 60-74 min | High | ~$237 |
99204 is under-billed, not over-billed
99204 gets treated as the code that draws attention, so practices round down to 99203 and tell themselves it is conservative. It is not conservative. It is wrong in the other direction, and being wrong in the other direction is still being wrong.
A real new patient visit in a specialty office looks like this: no problem list, so you build one. No baseline, so you order something. A referring physician’s records to read. A prescription to start or change. That is data at moderate and risk at moderate — two of three, before you have counted the problems column at all.
The spread is $60 a visit. A provider seeing six new patients a day, rounding three of them down, gives back roughly $45,000 a year on notes that already supported the higher level.
What actually protects you in an audit is not the level you picked. It is whether the note shows the work. Name the problems you addressed and their status. Say what you reviewed and where it came from. Say what you prescribed and why. A 99204 with that note survives. A 99203 with that note was simply underpaid.
Five mistakes that turn a clean 99204 into a denial
- Requiring all three MDM columns at moderate. You need two.
- Billing 99204 for a patient your partner saw within three years. Same group, same specialty means established.
- Using “45 or more minutes.” The range is 45 to 59. Over 59 is a 99205.
- Missing modifier 25 when a procedure happened the same day.
- Rounding down to 99203 out of habit when the note supports moderate.
Frequently asked questions
What is CPT code 99204?
A level 4 office or outpatient visit for a new patient, supported by either moderate-complexity medical decision making or 45 to 59 minutes of total time on the date of service. Either path qualifies on its own.
How much does 99204 pay in 2026?
About $177 nationally under Medicare, non-facility, before locality adjustment. The 2026 conversion factor is $33.40 for clinicians who are not qualifying APM participants and $33.57 for those who are, both effective January 1, 2026.
What counts as moderate medical decision making?
Two of three grid elements at moderate. Problems addressed: one chronic illness with exacerbation, two or more stable chronic illnesses, one undiagnosed new problem with uncertain prognosis, or an acute illness with systemic symptoms. Data: three combined items, an independent test interpretation, or discussion with an external clinician. Risk: prescription drug management, or a decision about minor or elective major surgery.
What is the difference between 99203 and 99204?
MDM complexity and time. 99203 is low-complexity MDM or 30 to 44 minutes; 99204 is moderate-complexity MDM or 45 to 59 minutes. Either path gets you there on its own. The payment difference is about $60 per visit.
Does prescribing a medication make a visit a 99204?
Prescription drug management puts the risk column at moderate on its own. You still need a second column at moderate, either problems addressed or data reviewed, because moderate MDM requires two of three.
Is 99204 an audit risk?
No more than any other level when the note supports it. Auditors compare the documented decision making to the level billed. The defensible note names the problems and their status, what was reviewed and its source, and what was prescribed and why.
Is 99204 affected by the 2026 efficiency adjustment?
No. CMS exempted time-based services, including the E/M office visit family 99202 through 99215, from the 2.5% efficiency adjustment applied to roughly 7,700 other codes in 2026. The work RVU for 99204 is unchanged at 2.60.
Can 99204 be billed with a procedure on the same day?
Yes, with modifier 25 appended to the E/M, and only when the evaluation was significant and separately identifiable from the procedure. Missing modifier 25 is one of the most common dermatology denials.
This article explains how these codes tend to get paid — it is not coding, billing, or legal advice. Some of the codes here are bundled into the main procedure, or fall into grey areas that vary by payer. Before billing anything in a grey area, confirm it with your own coding and compliance team and the current guidance from the American Academy of Dermatology (AAD), Medicare (CMS), and AMA CPT. When in doubt, don’t bill it.
