99204 CPT Code Description
99204 CPT Code: Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, 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. Typically, 45 minutes are spent face-to-face with the patient and/or family. Billing Instructions: Bill 1 unit per visit.
Level 4 New Patient Office Visit (99204)
This is the most popular code used to bill for new patients being seen in the office. Internists selected the 99204 code for 48.12% of these encounters in 2015. The 2017 Medicare allowable reimbursement for this level of care is $166.16 and it is worth 2.43 work RVUs. Usually the presenting problems are of moderate to high severity.
New Patient vs Established Patient
New patient visits used to be easy to distinguish from those with established patients. By CPT definition, a new patient is “one who has not received any professional services from the physician, or another physician of the same specialty who belongs to the same group practice, within the past three years.” By contrast, an established patient has received professional services from the physician or another physician in the same group and the same specialty within the prior 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|
New patient visits require more work than established patient visits at the same level, and this is reflected in the coding requirements as well as the reimbursement for new patient visits. For the new patient codes, the required components and the relative value units (RVUs) are greater than for established patient codes at the same level.
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
For accurate medical billing, knowing your CPT codes is the most important thing. In our blog series of ‘Know Your Codes’ or ‘KYC,’ we have discussed the most common CPT codes in detail and when to use them. E2E Medical Billing Services is known for it’s accurate and affordable medical billing services. To know more about our medical billing services call us at 888-552-1290 or write to us at info@e2eMedicalBilling.com