What is CPT Code 99204? Guidelines and Key Components

CPT Code 99204 – Introduction

In this article, you will learn about CPT code 99204, its components, its importance in the coding system and healthcare services, documentation requirements for this code, billing guidelines for 99204, modifiers with 99204, its examples, and frequently asked questions about 99204.

What is CPT code 99204?

CPT code 99204 is a medical code used in documenting and reporting the evaluation and management of a general outpatient visit for an established patient in a healthcare setup. This code reports services, including counseling and risk factor management, by the physician and other healthcare professionals.

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Description of CPT code 99204:

” Office or other outpatient visits for evaluating and managing a new patient require a medically appropriate history and/or examination and moderate medical decision-making. When using time for code selection, 45- 59 minutes of total time spent on the encounter date.”

What services does CPT code 99204 cover?

CPT 99204 covers the services required for a level-3 visit and the counseling and risk factor reduction interventions for many medical conditions. The services provided by healthcare professionals under 99204 may include the following:

Obtaining the history containing all required information about the patient
Performing a physical examination, including reviewing the body systems
Identifying the possible risk factors and developing a plan to reduce them
Promoting patient’s health and preventing disease with the help of counseling
Coordinating with Laboratories for Diagnostic purposes
Providing medical referrals to other health care providers and specialists if required

The key components of patient care under code 99204 of a new outpatient visit:

Under 99204, a new outpatient visit must contain the following key components:

A chief complaint of moderate to high severity
A comprehensive history of present illness( HPI): The history of present illness contains information about the patient’s current condition, including the onset, duration, severity (moderate to high severity under code 99204), location, modifying factors, timing, and associated symptoms. Document more than four elements from the list mentioned above should while documenting this code. Document all this information and the patient’s chief complaint for the evaluation’s sake.
A detailed review of systems (ROS): Review of systems (ROS) includes reviewing 2-9 systems of the body to gather detailed information about the complaint and any relevant medical conditions.
Past family and social history (PFSH):
It contains information about the patient’s medical history, including previous illnesses, surgeries, and medications. The patient’s family history includes hereditary diseases or conditions that may impact the patient’s health. Social history presents the patient’s lifestyle, occupation, and environmental factors. Cover at least two areas under this code documentation.

Physical Examination:

It is a detailed multi-system or focused physical patient evaluation under the evaluation and management guidelines. The chief complaint and the history of the present illness decide whether the examination should be detailed or focused. A physical examination identifies any signs of illness, abnormalities, or potential areas of concern. Document it should properly.

Medical Decision-Making (MDM):

Based on data, risk and severity, and diagnostic or therapeutic options as three critical components, the medical decision-making under code 99204 is of moderate complexity.

Counseling and Coordination of Care (CCC): Besides providing prescriptions and referrals, the health provider also includes discussing test results, reviewing treatment plan changes with specialists, and providing quality care after coordinating with other healthcare providers and specialists must include in the care provided under 99204.

Requirements for documenting CPT 99204 code:

Following are some of the requirements while documenting CPT 99204:

A detailed description of the patient’s chief complaint: The description should include the symptoms of the illness and their impact on the patient’s daily living activities.
A document containing the detailed history of the present illness, including the elements of HPI.
A complete physical examination document containing the review of the patient’s 2- 9 body systems.
A document containing the patient’s medical, family, and social history relating to the presenting complaint.
A document about medical decision-making at a moderate level, including assessment, diagnosis, and treatment plan, according to the information obtained during the visit.
A document mentioning the time of encounter, i.e., 45-59 minutes, is essential to indicate the services provided.
To show that the document is authentic and properly reviewed, it must be signed by the healthcare provider.

Billing guidelines for 99204:

As mentioned, 99204 bills in-office or outpatient evaluation and management (E/M) service for a new patient. Following are some of the guidelines to properly bill for this code:\

Proper documentation is important for appropriate billing. All the recommendation requirements, as mentioned above, should meet the criteria for a level 4 new patient office visit.

If counseling and coordination of care take more than 50% of the total encounter time, the visit can be billed based on the encounter time. In the case of 99204, this time must meet the minimum threshold of 45 minutes.

Ensuring the correct assignment of CPT code 99204 with any other relevant diagnosis codes based on the patient’s history is an important step while submitting the claim.

Documenting the complexity of the patient’s condition and the extent of evaluation and management is important to establish a medical necessity for the level 4 visit, which is needed to submit a claim.

The claim must comply with the billing guidelines provided by the Centers for Medicare and Medicaid (CMS) and any other relevant payer guidelines.

Double-check the reimbursement rates for 99204, as they vary according to the payer policies and the specific geographic locations.

Commonly used modifiers with 99204:

The following are the most commonly used modifiers with 99204:

Modifier 24

Modifier 25

Modifier 57

Modifier 95

Summary of 99204:

History: Comprehensive

Chief complaint: 1

History of Present Illness (HPI): More than four elements

Review of Systems (ROS): 2-9 systems

Past Medical, Family, and Social History (PFSH): At least two elements

Severity: Moderate to high

Medical Decision-Making (MDM): Moderate complexity

Time of encounter: 45-59 minutes

Frequently asked questions about CPT code 99203:

What level of Medical Decision-Making is required for 99204?

99204 requires moderate-level medical decision-making.

What modifiers can we commonly use with 99204?

Modifiers 24, 25, 57, and 95 can append with 99204.

Can we append modifier 25 with 99204?

Modifier 25 appends with 99203 if the same physician provides any significant, separately identifiable evaluation and management (E&M) service on the same day of the encounter.

What should be the time of the patient-physician encounter while billing 99204?

The time with the physician should be 45-59 minutes for 99204.

Grants for Medical

CPT Code 99204