99204 CPT Code Description
99204 CPT Code Description
Office or other outpatient visits for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. As per 99204 CPT code description, physicians typically spend 45 minutes face-to-face with the patient and/or family.
A new patient is defined as a patient who has not received professional services from a doctor or another doctor of the exact same specialty and subspecialty who belonged to the same group practice within the past three years.
|E/M Code||History||Physical Exam||MDM||Time|
|CPT Code 99201||Problem Focused||Problem Focused||Straightforward||10|
|CPT Code 99202||EPF||EPF||Straightforward||20|
|CPT Code 99203||Detailed||Detailed||Low||30|
|CPT Code 99204||Comprehensive||Comprehensive||Moderate||45|
|CPT Code 99205||Comprehensive||Comprehensive||High||60|
*Face-to-face time refers to the time with the physician only. Counseling by other staff is not considered to be part of the face-to-face physician/patient encounter time.
CPT Code 99204 (3 of 3 components required)
|Comprehensive History & Exam||Chief Complaint |
An extended history of present illness, review of systems which is directly related to the problem(s) identified in the history of the present illness plus a review of all additional body systems
Complete past, family, and social history
|Moderate Medical Decision Making||Multiple number of diagnosis or management options|
A moderate amount of data
Moderate risk of complication and/or morbidity or mortality
|Presenting Problem (severity)||Moderate to High|
The comprehensive history obtained as part of the preventive medicine evaluation and management service is not problem-oriented and does not involve a chief complaint or present illness. It does, however, include a comprehensive system review and comprehensive or interval past, family, and social history as well as a comprehensive assessment/history of pertinent risk factors.
History of Present Illness (HPI)
A chronological description of the development of the patient’s present illness from the first sign and/or symptom or from the previous encounter to the present. Descriptions of present illness may include: Location, Quality, Severity, Timing, Context, Modifying Factors, and Associated signs/symptoms significantly related to the presenting problem(s).
The Chief Complaint is a concise statement from the patient describing: The symptom, Problem, Condition, Diagnosis, Physician recommended return, or other factor that is the reason for the encounter.
- Review the medical history form completed by the patient and vital signs obtained by clinical staff
- Communicate with other health professionals
- Obtain a comprehensive history
- Perform a comprehensive examination o Consider relevant data, options, and risks and formulate a diagnosis and develop a treatment plan (moderate complexity medical decision making)
- Discuss diagnosis and treatment options with the patient
- Address the preventive health care needs of the patient
- Reconcile medication(s)
- Write prescription(s)
- Order and arrange diagnostic testing or referral as necessary
- Complete the medical record documentation
- Handle (with the help of clinical staff) any treatment failures or adverse reactions to medications that may occur after the visit
- Provide necessary care coordination, telephonic or electronic communication assistance, and other necessary management related to this office visit
- Receive and respond to any interval testing results or correspondence
- Revise treatment plan(s) and communicate with patient, as necessary
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