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CPT 99204: New Patient Office Visit, Moderate Complexity
CPT code 99204 denotes an evaluation and management (E/M) outpatient visit for a new patient characterized by moderate medical decision making or by at least 45 minutes of total clinician time on the date of service. Nationally, this code is used to document comprehensive new patient assessments in ambulatory settings and is a common component of primary care and general practice workloads. Key payers included in this analysis are Aetna, Blue Cross Blue Shield, Cigna Health, United Healthcare, and Medicare. Readers will find a concise overview of clinical context for use of 99204, operational implications for outpatient practices, and comparisons to adjacent new-patient E/M codes such as 99203 and 99201. The publication summarizes typical sites of service, common presenting diagnoses appropriate for this level of visit (for example headache, abdominal pain, upper respiratory infection, hypertension, and diabetes without complications), and the linkage to general practice taxonomies. It also covers billing considerations relevant to national payers and highlights what to expect in terms of coding criteria and documentation thresholds. Data not available in the input is noted where applicable. This report is intended for administrators, coding professionals, and policy analysts seeking a national-level briefing on the clinical and billing role of CPT code 99204.
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Billing Code Overview
CPT code 99204 describes an office or other outpatient visit for a new patient involving a moderate level of medical decision making, or when the provider spends 45 or more minutes of total time on the encounter on a single date. The service type is an Evaluation and Management (E/M) outpatient new patient office visit, and the typical site of service is an office or other outpatient clinic setting.
National Reimbursement Benchmarks
Nationally, Medicare averages $182.5 for CPT 99204 while BUCA’s commercial average is higher at $221.7, creating a $39.2 gap between public and commercial mean rates. This differential highlights that average commercial reimbursement (BUCA) sits meaningfully above the Medicare mean, with other major commercial payers like Blue Cross Blue Shield and UnitedHealth Group showing even higher means in many localities.
Rate dispersion (P75 minus P25) varies notably across payers. Blue Cross Blue Shield and UnitedHealth Group show wider interquartile spreads of $86.5 and $131.7 respectively, indicating greater variability; Aetna and Cigna are tighter at $127.6 and $122.9 respectively, while BUCA’s IQR is $104.0. Medicare’s IQR is narrowest at $15, reflecting relatively consistent local Medicare rates.