CPT Code 99204: What You Need To Know In 2024

March 18, 2024

CPT Code 99204: What You Need To Know In 2024

Today we’ll show you exactly what CPT code 99204 is, when to use it, and why you should use it.

In turn, you can take better care of your patients and put more money in your pocket for doing the exact same amount of work – just by coding better.

Or, you can always outsource this stuff to an all-encompassing billing and coding company like us if you want to give 100% of your focus to your patients…we’re just a call or email away!


Key Points:

  • CPT code 99204 is designated for new patient office or outpatient visits that require a moderate complexity in medical decision-making or 45-59 minutes of patient encounter time.
  • Proper documentation and accurate code selection are crucial for maximizing reimbursement with CPT code 99204. 
  • Understanding the differences between CPT codes 99203, 99204, and 99205 is essential for accurate billing and reimbursement, as these codes vary by the level of history, examination, medical decision-making complexity, and typical time spent with the patient.

What is CPT Code 99204?

CPT code 99204 is designated for an office or outpatient visit for assessing and managing a new patient, requiring a medical history and/or examination with a moderate complexity of medical decision-making.

If choosing the code based on time, the encounter involves 45-59 minutes of total time on the visit date.

It’s tailored for instances where a comprehensive assessment is necessary to understand and address the patient’s health concerns.

CPT Code 99204 Description: New patient visits requiring comprehensive evaluation, moderate complexity decision-making, and 45-59 minutes of encounter time, typically involving detailed history, examination, and care planning.

What is CPT Code 99204 Used For?

CPT code 99204 is applied in scenarios that require a detailed evaluation of a new patient, often due to the new patient having a progressing illness or acute injury. 

Scenarios where CPT code 99204 is also used include:

  • Patients with multiple health issues needing a comprehensive review.
  • Situations where the diagnosis is uncertain, and a detailed examination can guide the management plan.

The Importance of CPT Code 99204 in Patient Care & Billing

Properly using CPT code 99204 ensures that you as the provider are adequately reimbursed for the time and expertise you bring to the assessment of the new patient – that’s a win-win for both your patient and your bank account!

It also facilitates a thorough evaluation, giving providers a detailed understanding of the patient’s health, ultimately leading to an effective treatment plan. 

CPT Code 99204 Requirements

New patient codes (99202-99205) used to need the three key components of medical decision-making (MDM), a medical history, and a detailed examination of the patient. 

Changes were made in 2021 that put more emphasis on medical decision-making and/or total time spent with the patient on the encounter date (these changes also affected codes like 99214 and 99205, amongst others).

Criteria to code for 99204 in 2024 is (again, with emphasis on MDM and service time):

  • A moderate level of medical decision-making
  • 45-59 minutes of patient visit time
  • A comprehensive medical history/patient examination

99204 CPT Code Reimbursement Rates in 2024

The Medicare reimbursement rate for CPT code 99204 in 2024 is set at $164.38.

Code 99204 is the most popular code for billing new patients seen in the office, with internists choosing it for 49.61% of these types of encounters. It’s obviously an important code, with a high reimbursement value. 

And yet, many physicians miss out on a lot of opportunities to use this code…and others.

If lost revenue and spending too much time coding and doing paperwork is something you want to remove from your busy life, let us know and we can take care of all that for you – and more!

Common Mistakes to Avoid in Billing CPT Code 99204

Billing mistakes result in a lot of lost revenue and headaches.

We like to call ourselves the miracle pill for those headaches, taking all the pain away – anyways, here are some common pitfalls and mistakes in billing 99204s:

  • Overcoding & Undercoding: Ensure the visit complexity accurately reflects CPT code 99204 requirements so that you don’t use it too much or too little.
  • Inadequate Documentation: Proper documentation is necessary to support the billing of CPT code 99204.
  • Ignoring Time-Based Billing Criteria: Accurately record the time spent on patient care to justify the use of this code!
  • Misunderstanding Patient Status: CPT code 99204 is specifically for new patients. Ensure accurate patient categorization to avoid billing errors (AKA more headaches).
  • Not Staying Updated with Coding Changes: Coding guidelines evolve, and staying informed is essential for accurate billing.

A couple ways you can stay ahead of these things is by:

  • Maintaining detailed documentation of each patient visit, emphasizing the complexity of MDM.
  • Regularly updating billing practices with the latest guidelines.
  • Educating yourself and your team on the nuances of CPT code 99204 and how to avoid common errors (like by asking us!).

CPT Code 99203 vs. 99204 vs. 99205

The main differences among these codes are in the complexity of the visit and the requirements for documentation (much like the differences between ICD-9 and ICD-10)… 

Choosing the right codes is super important to avoid billing issues and to make sure you get the proper reimbursement:

  • CPT Code 99203 is used for new patients requiring a detailed history, detailed examination, and low complexity in medical decision-making. It’s great for visits that need a moderate level of evaluation and management.
  • CPT Code 99204 represents a step up in complexity, designated for visits that require a comprehensive history, comprehensive examination, and moderate complexity in medical decision-making. This code is for more complicated patient cases that require an extensive evaluation.
  • CPT Code 99205 takes it up another notch and is used for the most complex cases involving new patients, requiring a comprehensive history, comprehensive examination, and high complexity in medical decision-making. It’s reserved for the most challenging and time-consuming patient evaluations.

Below is a table summarizing the key differences based on the E/M coding changes in 2021, including for time: 

CodeHistory/ExamMDMEncounter Time (minutes)
99203Medically appropriate history and/or examinationLow30-44
99204Medically appropriate history and/or examinationModerate45-59
99205Medically appropriate history and/or examinationHigh60-74
From AAPC

Conclusion

With the ever-changing requirements for CPT codes such as 99204, it can be a tricky (and even frustrating) process trying to accurately code your patient visits and get properly reimbursed.

You need to constantly educate yourself, audit and analyze your billing process, and split your time between patients and paperwork, often losing out on money and even affecting patient care. 

We at The Auctus Group are pros in medical billing and coding, and offer a wide range of services that takes complete care of this messy process…

Shoot us a message or give us a call and we’ll be happy to help out…and fix that headache for you!

FAQs

What type of exam is required for a 99204?

A medically appropriate history and/or examination that requires moderate medical decision-making.

What is the rate for CPT code 99204?

The Medicare reimbursement rate for 2024 is $164.38.

What is the difference between 99203 and 99204?

The primary difference lies in the complexity of medical decision-making and the required time. 99204 requires moderate medical decision-making, with a session length of 45 – 59 minutes, indicating a more complex patient visit compared to 99203.

What is the CPT code for a new patient visit?

New patient visits are covered by codes 99201-99205, with the specific code depending on the complexity of the visit.

What is an example of a 99204 patient?

A new patient presenting with multiple symptoms that require a detailed history, a comprehensive examination, and moderate complexity in medical decision-making.

What is the difference between code 99205 and 99204?

Code 99205 is used for new patient visits that require a comprehensive history and examination and high complexity medical decision-making, indicating a higher level of complexity than 99204.

What modifier is needed for 99204?

Modifiers for 99204 depend on the specific circumstances of the billing situation (e.g., -25 for a significant, separately identifiable service by the same physician on the same day of the procedure or other service or modifier 22 for a significantly more complex procedure).

Can 99204 and 99386 be billed together?

Generally, 99204 (office visit) and 99386 (preventive medicine service for a new patient of a certain age) might not be billed together for the same patient on the same day as they cover different aspects of care. However, specific situations and payer rules may allow it with appropriate modifiers.

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