Which code is used for a moderate level new patient exam?

• A. 99204
• B. 99202
• C. 99203
• D. 99205

Answer: (A)

Coding a new-patient office visit hinges on matching the documented time and the level of history, exam, and medical decision making. A moderate level for a new patient typically means a thorough history, a fairly comprehensive exam, and a moderate level of medical decision making, usually around 45–59 minutes of face-to-face time. This combination corresponds to the mid-range code for a new patient visit, which is chosen when the documentation supports that amount of time and complexity. The lower levels reflect shorter visits with less comprehensive history and exam, while the highest level corresponds to high complexity and longer time. So, the mid-range code best fits a moderate level exam, provided your notes justify the 45–59 minute contact and the moderate MDM. Ensure your documentation clearly reflects the history, exam findings, and MDM level to support that code.