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99204 vs 99205: Billing High-Complexity New Patient E/M

Last Updated: July 12, 2026

Billing 99204 ↗ (Moderate Complexity) or 99205 ↗ (High Complexity) is heavily audited because these are the highest-paying office visit codes for new patients.

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2026 Medicare National Fee (99204): Non-Facility (Office): $214.82 · Facility (Hospital): $129.58
✓ 111 Medicare-Approved ICD-10 Diagnoses on file for 99204:

The "New Patient" 3-Year Rule

A new patient is one who has not received any professional services (E/M or surgical) from the physician, or another physician of the exact same specialty and subspecialty within the same group practice, within the past exactly 3 years.

Time vs. MDM for 99204 and 99205

If billing by time:

  • 99204: 45 - 59 minutes total time
  • 99205: 60 - 74 minutes total time

If billing by MDM, a 99205 requires a "High" level of complexity, meaning severe exacerbations, threats to life/bodily function, or decisions regarding major surgery with identified risk factors.

NCCI Edit Warnings

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Not sure if these codes bundle? Check the latest Medicare NCCI database updates before you bill.

If a new patient requires an immediate minor procedure during the visit, you must append Modifier 25 to the 99204/99205. Check your NCCI combinations carefully.

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