New Patient Office Visit – 45 to 59 Minutes

CPT Code: 99204

Description: This code applies to new patient visits that typically last between 45 and 59 minutes. The visit requires a detailed history, a detailed exam, and moderate complexity MDM.

Key Components:

• History: Detailed
• Examination: Detailed
• Medical Decision Making: Moderate complexity

The code can be justified either by meeting the key components or by the total time spent (including counseling/coordination of care).

Documentation Tips:

• Provide comprehensive details of the patient’s history and exam.
• Document the moderate complexity decision-making process thoroughly.
• Include the total face-to-face time if using time-based coding.

Review current guidelines regularly to ensure your documentation supports this level of service.