CPT
90471 — Immunization administration, single vaccine
ACA-covered vaccines should be free, including the admin fee.
Office & outpatient evaluation
99204 — New patient office visit, moderate complexity (45 min)
A first-time visit with moderate-complexity decision-making. ~45 minutes of provider time. Frequent upcoding target.
- Typical setting: Doctor's office
- National avg charge (illustrative): Insurance allowed $140-$310; cash $250-$600.
- Most-disputed reason: Documentation doesn't support moderate complexity.
What it means
What 99204 actually means
CPT 99204 is the level-4 new-patient visit, implying moderate-complexity medical decision-making. The chart should show either a chronic illness with progression, a new problem with prescription management, or multiple problems being addressed.
Common errors with this code
What goes wrong on real bills.
Most bills that look correct still contain at least one of these issues. Up to 49% of medical bills contain errors (CFPB).
- Visit was straightforward but billed as 99204 anyway.
- Time-based billing claimed but actual visit time not documented in note.
- Two charges (E/M + facility fee) when the location is a hospital outpatient department.
If you see 99204 on your bill
Three steps before paying.
1. Get the itemized bill. If your statement only shows a summary, request the CPT-level itemized bill before paying. Generate the request language →
2. Cross-check against the EOB. Compare what your insurer's Explanation of Benefits says you owe versus what the hospital is asking. They disagree more often than people think. Read the bill-vs-EOB guide →
3. Run a free Bill Scan. Upload the bill (and EOB if you have it) and BillBusted will flag the most likely issues with this specific code in your specific state. Run free scan →
Related codes
Other codes in this category.
People who land on 99204 often also see these adjacent codes on the same bill.
CPT
90472 — Immunization admin; each additional vaccine
Vaccine — admin (90471) is separate from the vaccine product code.
CPT
90651 — Human papillomavirus vaccine types 6, 11, 16, 18, 31, 33, 45, 52, 58, nonavalent , IM
Vaccine — admin (90471) is separate from the vaccine product code.
CPT
90670 — Pneumococcal conjugate vaccine, 13 valent , IM
Vaccine — admin (90471) is separate from the vaccine product code.
CPT
90671 — Pneumococcal conjugate vaccine, 15 valent , IM
Vaccine — admin (90471) is separate from the vaccine product code.
CPT
90677 — Pneumococcal conjugate vaccine, 20 valent , IM
Vaccine — admin (90471) is separate from the vaccine product code.
Related BillBusted guides
Plain-English reads if you see 99204 on a bill.
99204 FAQ
Plain-English answers.
What's the difference between 99203 and 99204?
Decision-making complexity. 99203: low complexity, single problem, straightforward. 99204: moderate complexity, multiple problems, chronic illness, or a new problem requiring prescription management.
Don't pay 99204 blindly.
The free scan tells you in under 60 seconds whether this charge looks reasonable for your situation.