99204 cpt code

99204 CPT Code (2022) – Billing Guidelines, Modifiers & Examples

99204 CPT code is used to report for new patient services rendered in the office, other outpatient hospital settings, or multi-specialty clinic groups.

It is required medically necessary history and/or physical exam but will no longer contribute to the code selection of Evaluation and Management codes (CPT 99202-99215).

99204 CPT Code Intro

As per 2021 guidelines, Code selection will be based on the total time spent by the provider or other qualified healthcare professional and/or medical decision making (MDM) during the patient’s encounter to enhance payment accuracy, lower administrative burden, and reflects the current medical practice. 

Multiple factors would be considered for code selection based on MDM or Time.

Medical Decision Making (MDM) includes the count and nature of presenting problem seen in the encounter; what kind of studies and complications have been reviewed like from medicine, radiology, and pathology sections; and possible outcome of that complication and/or Mortality and Morbidity of patient management”.

CPT 99202 is used to report the minor or self-limited problem which typically requires 15-20 minutes and straightforward MDM spent by the provider during the encounter.

CPT 99203 entails a low level of MD and requires 30-44 minutes.

99204 CPT code is requiring a moderate level of MDM and 45 to 59 minutes of total time spent by the provider, and CPT 99205 for an encounter needing High-level MDM and 60-74 total time lasts during the encounter.

This CPT includes both face-to-face and non-face to-non face services provided by the Physician and other qualified healthcare professionals in an encounter.

Modifier 95 is applicable with E/M (CPT 99202-99215) to report telehealth services provided by the Physicians or other qualified healthcare professionals.

If telehealth services are provided at originating sites like Hospitals, and the Physician’s office, then reports the Q3014 HCPCS Level II code instead of E/M CPT 99202-99215.

cpt 99204

99204 CPT Code Description

99204 CPT code is used to bill office or other outpatient hospital services for evaluation and management of the new patient, which requires medically necessary history and or exam, entails a moderate level of MDM.

It needs 45-59 minutes of total time spent in an encounter.

A new patient is an individual who has never had seen by the provider or provider with the particular same specialty or same group either non-face to-face or face to face within the past three years.

When a patient is supposed to be seen by a provider on-call or who is not available at the time of encounter, and done by Covering Physician or healthcare professional.

This service would be considered for the provider who is not available instead of the Covering Physician. 

Billing Guidelines

There are the following billing guidelines that are appropriate with CPT 99204:

If any service is provided in Emergency Department (CPT 99281-99285), Hosptial Observation (CPT 99217-99220, CPT 99224-99226), Inpatient Hospital or Hosptial Observation with same-day admission and discharge service in conjunction with an office visit (CPT 99204) are separately billable. 

CPT 99204 does not require History and/or Physical exam for code selection but should include in the E/M service that is medically appropriate. 

CPT 99204 will be required a moderate level of Medical Decision making (MDM). It requires at least 2 out of 3 components of MDM must be met as Moderate. There are the following 3 components of MDM:

  1. Number and Complexity of Problems
  2. Amount and/or Complexity of Data to be Reviewed and Analyzed
  3. Risk of Complications and/or Morbidity or Mortality of Patient Management

CPT 99204 Modifiers

There is the following list of modifiers that apply to 99204 CPT code. Modifier25, 24, 27, 33, 57, 95, 99, AI, AQ, AR, CR, CC, CS, EY, ET, GO, GA, GE, GC, GJ, GK, GQ, GR, GT, GU, GY, GZ, KX, Q5, Q6, QJ & TH.

The most frequently used modifiers are 24, 25, 57, and 95 append with CPT 99204. Modifier 95 is often used for Telehealth services nowadays due to the current Covid 19 Pandemic situation.

Modifier 57 is applicable when an E/M visit (99204 CPT code) is initiated for the decision of surgery on a day of surgery or the day before surgery.

For Instance, a patient presents to the office and the Physician decided to perform surgery like a laparoscopic appendectomy by tomorrow.

The laparoscopic appendectomy CPT 44970 has 90 days global period. The day before surgery, day of surgery, and are related E/m services are included in 90 days global period.  It would be billed like:

CPT 99204 – 57, K35.32 DOS 1-25-2022

CPT 44970 – K35.32 DOS 1-26-2022

Modifier 25 is used to report services that are performed on the same day in combination with distinct E/M service (99204 CPT code) which are separately payable.

Example

A 45 years old male presented in the physician’s office with a laceration of the head. The physician applied sutures to his head during the visit, the Patient’s son asked for the high blood sugar medications and decided to do a comprehensive physical exam.

Therefore, it would be billed like:

CPT 12001 – S01. 91XA

CPT 99204 – 25-R03.0

While modifier 24 is applicable for services like major surgery performed about 2 months ago and currently for unrelated conditions to surgery. Modifier 24 will be appended with that unrelated E/M service.

99204 cpt code description

Reimbursement

CPT 99204 is appropriate to bill with POS 11 (Clinician’s office) or POS 22 (represents Hospital outpatient facility).

If there is any other services or procedure provided on the same day in conjunction with E/M that is distinct or separately identifiable service, modifier 25 is allowed to append with that service.

A maximum of 1 unit of 99204 can be billed on the same day by the Same Physician or 2 units can be billed for unavoidable circumstances with proper medical documentation support on a given date.

The RUV’S of 99204 CPT code are 4.63 and 3.66 for non-facility and facility settings respectively in 2021, increasing to 4.93 and 3.96 in the year 2021. CPT 99204 cost would be around $145.72 and $184.35 for facility and non-facility settings respectively.

Examples

The following are examples of when it is appropriate to use 99204 CPT code.

Example 1

58 y/o male with a PMH of HTN, HLD, hypothyroidism presenting to the hospital outpatient setting because of a headache and high blood pressure before arrival.

The patient was laying down in bed at 10 pm when he began having a gradual onset pulsating frontal and occipital headache. He reports the pain became very severe.

His headaches are usually associated with HTN and when he took his BP it was 210/100. He denies associated dizziness, chest pain, shortness of breath, motor weakness, numbness/tingling, abdominal pain, nausea/vomiting.

The physician ordered a series of diagnostic tests CT, MRI, and EKG. EKG was independently interpreted and reviewed by the Physician. Patient reports improvement in HA with Tylenol. 

Example 2

51 y/o f with hx of hld coming in for an episode of syncope/near syncope tonight which was witnessed by her partner.

She began using a Nicotine patch for the first time tonight. One hour after using a nicotine patch while laying in bed she had a brief episode of feeling hot, numbness, and tingliness in her b/l hands, “gas discomfort” in her stomach, headache.

When she tried to get up she lost consciousness(witnessed by her partner, who I spoke to for more hx).

Partner states she was only out for a few seconds before perking up to normal. Pt states she has had episodes like this in the past but several years ago. No known cardiac hx. 

Physicians plan to order CBC, CMP, mg, phos, trop, EKG, Tylenol, Pepcid, Zofran

EKG: Normal sinus rhythm. 70 bpm. No ST elevation or T wave inversions. 

CXR: My interpretation showed no acute abnormalities.

Example 3

36 yo male PMH HTN, HLD, Afib (on eliquis), Mitral valve replacement, gout presenting to the Office today for dark blood stools for 2 days.

States that he started having diarrhea yesterday and has had a total of 4 BM in the past 2 days.

Denies nausea, vomiting. Denies CP, SOB, dizziness. Denies any fevers, chills, Last took eliquis this morning.

He also notes worsening bilateral lower extremity edema for which he takes Lasix. He has also been taking Indomethacin for the past 4 days for a presumed gout flare. 

Last colonoscopy 3 years ago, found benign polyp but otherwise WNL. Physicians plan to admit and Plan Labs, EKG, CT abdomen, and Pelvis, and prescribed Medicine.

Example 4

70 y.o female with hx of HLD presenting to the OPD for substernal chest pain. She worked out daily, very healthy active senior, lived at home.

She was working out today. After the workout, she took a sip of water, and she had substernal chest pain, none radiating, associated with weakness. However, Gatorate helped with the substernal chest pain.

She had no chest pain shortly after, however, her trainer told her to see a provider. She went to urgent care with asymptomatic resolved chest pain, they sent her over here because she had a family hx of MI in her family.

Her brother died of MI at age 48 EKG without ischemic changes. Low suspicion for ACS. HEART score 3.

Example 5

38-year-old female past medical history of chronic gastritis diagnosed on endoscopic 2 weeks ago presenting with 1 month of on and off palpitations and lightheadedness. 

The patient states that she has been feeling off for the last month and describes her symptoms as when she wakes up in the morning she feels fogginess has bouts of palpitations with associated lightheadedness without syncope.

The patient cannot pinpoint a trigger and states her symptoms resolve on their own. Palpitations last anywhere from seconds to minutes.

The patient endorses that she has a healthy diet and does not do any narcotics drink alcohol or smoke. 

Pt otherwise denies fevers, chills, syncope, headaches, neck pain, chest pain, shortness of breath, back pain, abdominal pain, nausea, vomiting, diarrhea, constipation.

The physician decided will obtain EKG labs chest x-ray reassess.

EKG normal sinus rhythm at 74 bpm with a QTC of 426 no ST elevations or depressions.

By Uzair Ali Murtaza
Expert Medical Coding & Billing

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