Reimbursement
$168.67
Threshold
45m
2026 Status
Active
What is CPT Code 99204?
CPT 99204 is defined as: 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 time for code selection, 45-59 minutes of total time is spent on the date of the encounter.
This code is primarily used for E/M services. It falls under the category of Evaluation & Management and is valid for the 2026 calendar year according to the CMS Physician Fee Schedule.
2026 RVU Components
Relative Value Units (Non-Facility)
Work RVU
2.6
Physician Effort
PE (Non-Fac)
2.22
Practice Expense
Malpractice
0.23
Risk Factor
Total RVU
5.05
Note: [(Work RVU * Work GPCI) + (PE RVU * PE GPCI) + (MP RVU * MP GPCI)] * Conversion Factor
2026 CMS Policy Intelligence
efficiency shield
Protected from the -2.5% productivity adjustment (E/M service).
g2211 leverage
High ROI when combined with G2211 for longitudinal specialist care.
Administrative Framework
Place of Service
Key Modifiers
Operational Requirements
selection criteria
Moderate MDM OR 45-59 minutes total time.
patient status
New patient.
frequency
Once per encounter.
Compliance Checklist
Audit Defense
mdm moderate
Must meet 2 out of 3 MDM categories: 1) Complexity of problems; 2) Data reviewed; 3) Risk of management.
2026 Update
2026 valuation confirms 99204 as a high-work-effort code. Ensure time spent in 'readying' the chart counts toward total time.
Common Clinical Scenarios
Target Specialties & Utilization
Typical Clinical Indications (ICD-10)
Frequently Asked Questions
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