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 requires medically necessary history and/or physical exam but will no longer contribute to the code selection of Evaluation and Management codes (CPT 99202-99215).
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 reflect 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 the presenting problem seen in the encounter; what kind of studies and complications have been reviewed by Medicine, radiology, and pathology sections; and the possible outcome of that complication and/or Mortality and Morbidity of patient management”.
CPT 99202 reports 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 requires a moderate level of MDM and 45 to 59 minutes of total time spent by the provider, and CPT 99205 for an encounter needs a level of MDM and 60 to 74 total time during the encounter.
This CPT includes 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 Physicians or other qualified healthcare professionals.
If telehealth services are provided at originating sites like Hospitals and the Physician’s office, report the Q3014 HCPCS Level II code instead of E/M CPT 99202-99215.
Description of CPT Code 99204
The 99204 CPT code is used for billing office or other outpatient hospital services to evaluate and manage the new patient, which requires medically necessary history and an exam that entails a moderate level of MDM.
The official description of CPT 99204 is: “Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 45-59 minutes of total time is spent on the date of the encounter.“
A new patient is an individual who has never been 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 a Covering Physician or healthcare professional.
This service would be considered for the provider who is unavailable instead of the Covering Physician.
There are the following billing guidelines that are appropriate with CPT 99204:
If any service is provided in the Emergency Department (CPT 99281-99285), hospital observation (CPT 99217-99220, CPT 99224-99226), Inpatient Hospital or hospital observation with same-day admission and discharge service in conjunction with an office visit (CPT 99204) are separately billable.
CPT 99204 does not require a History and/or Physical exam for code selection but should be included 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 MDM components to moderate. There are the following three components of MDM:
- Number and Complexity of Problems
- Amount and/or Complexity of Data to be Reviewed and Analyzed
- Risk of Complications and/or Morbidity or Mortality of Patient Management
How to use Modifiers with CPT code 99204
The most frequently used modifiers are 24, 25, 57, and 95 append with CPT 99204. Modifier 95 has often been used for Telehealth services since the COVID-19 Pandemic.
Modifier 57 applies when an E/M visit (99204 CPT code) is initiated for the decision of surgery on the day of surgery or the day before.
For Instance, a patient presents to the office, and the Physician decides to perform surgery like a laparoscopic appendectomy by tomorrow.
The laparoscopic appendectomy CPT 44970 has 90 days global period. The day before surgery, the day of surgery, and related E/m services are included in the 90-day 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 reports services performed on the same day in combination with distinct E/M services (99204 CPT code), which are separately payable.
A 45-year-old male presented in the Physician’s office with a head laceration. 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 two months ago and currently for unrelated conditions to surgery. Modifier 24 will be appended with that unrelated E/M service.
CPT 99204 is appropriate to bill with POS 11 (Clinician’s office) or POS 22 (represents Hospital outpatient facility).
If any other services or procedure is provided on the same day in conjunction with E/M that is a 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 two units can be billed for unavoidable circumstances with proper medical documentation support on a given date.
The RUV of 99204 CPT codes are 4.63 and 3.66 for non-facility and facility settings, respectively, in 2021, increasing to 4.93 and 3.96 in 2021. CPT 99204 costs around $145.72 and $184.35 for facility and non-facility settings, respectively.
The following are examples of when using the 99204 CPT code is appropriate.
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 lying in bed at 10 p.m. 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; 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.
51 y/o f with hx of held 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 tingling in her b/l hands, “gas discomfort” in her stomach, and headache.
She lost consciousness when she tried to get up (witnessed by her partner, whom I spoke to for more hours).
Partner states she was only out briefly before perking up to standard. Pt states she has had episodes like this, but several years ago—no known cardiac hx.
Physicians plan to order CBC, CMP, mg, phos, trop, EKG, Tylenol, Pepcid, and Zofran.
EKG: Normal sinus rhythm. 70 bpm. No ST elevation or T wave inversions.
CXR: My interpretation showed no acute abnormalities.
36 yo male PMH HTN, HLD, Afib (on eliquis), Mitral valve replacement, gout presenting to the Office today for dark blood stools for two days.
He states that he started having diarrhea yesterday and has had 4 BM in the past two days.
Denies nausea and vomiting. Denies CP, SOB, and dizziness. Denies any fevers or chills; Last took eliquis this morning.
He also notes worsening bilateral lower extremity edema for which he takes Lasix. He has also taken Indomethacin for the past four days for a presumed gout flare.
70 y.o female with hx of HLD presenting to the OPD for substernal chest pain. She worked out daily, was very healthy, was an active senior, and lived at home.
She was working out today. After the workout, she took a sip of water and 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 history of MI.
Her brother died of MI at age 48 EKG without ischemic changes. Low suspicion for ACS. HEART score 3.
A 38-year-old female with a medical history of chronic gastritis diagnosed endoscopically two weeks ago presented with one 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 foggy and has bouts of palpitations with associated lightheadedness without syncope.
The patient cannot pinpoint a trigger and states her symptoms resolve independently. 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.
The patient denies fevers, chills, syncope, headaches, neck pain, chest pain, shortness of breath, back pain, abdominal pain, nausea, vomiting, diarrhea, and constipation.
The Physician decided to obtain EKG labs and a chest X-ray reassessment.
EKG normal sinus rhythm at 74 bpm with a QTC of 426, no ST elevations or depressions.