Do you find it difficult to bill E/M services? Many physicians face the same problem. The main reason? Evaluation & Management (E/M) services are primarily cognitive, meaning they involve intangible processes, such as diagnosing patients and making medical decisions. Insurance companies require comprehensive documentation to evaluate the level of each E/M service you have provided. Moreover, there is always a high chance of over- and undercoding.
Are you confused between different E/M codes for new patients? You are at the right place! Today, we will explore the specifics of CPT code 99204, including description and real-world examples, so you can receive proper reimbursements. Read on to learn everything about this essential E/M code.
CPT Code 99204 – Description
How frequently do you face claim denials for your E/M services? You might be using the wrong code. CPT code 99204 is one of the high-level E/M codes for new patients. It simply covers office or other outpatient visits. Before moving on to what this encounter entails and how long it lasts, let us clarify what a new patient is.
According to the American Medical Association (AMA), a new patient is usually an individual who has previously not received any medical attention from the physician or their group practice in the last 3 years. This group practice includes other physicians and qualified healthcare professionals of the same specialty or subspecialty.
In simple words, CPT code 99204 specifies an initial face-to-face patient encounter with the doctor. During this visit, the doctor spends 45 to 59 minutes evaluating the patient and making moderate-complexity medical decisions. But how do you determine the complexity level of a medical decision?
The AMA classifies medical decision-making (MDM) into four levels, straightforward, low-level, moderate, and high-level decisions, based on three factors:
- Number and complexity of addressed problems
- Amount and/or complexity of data to be reviewed
- Risk of complications
So, if you address more than one problem, interpret various diagnostic results, and manage moderate risks of complications, you can choose CPT code 99204. The key components of this code include:
- Comprehensive medical history of a patient
- Medical examination
- Medical decision-making (moderate complexity)
- Timing (45 to 59 minutes)
Scenarios Where CPT Code 99204 is Applicable
Confused between total time and the complexity of medical decision-making (MDM)? Here are a few scenarios where you can use CPT code 99204.
Acute Illness with Systemic Symptoms
A 27-year-old woman with fever, chills, and occasional blood in her urine visits a doctor. The doctor spends 55 minutes taking a comprehensive history, such as past illnesses and medications, and conducting a detailed examination. He prescribes a urinalysis, blood test, and CT scan of the kidneys to determine if the patient has pyelonephritis (kidney infection).
Since the doctor evaluated an acute illness with systemic symptoms of moderate complexity, he used CPT code 99204 to report this encounter.
Evaluating & Managing A New Patient with Chronic Illness (Anxiety Worsened by Panic Attacks)
A 29-year-old woman visits a clinic due to anxiety and frequent panic attacks within a week. The psychiatrist reviews her symptoms, which include palpitations, chest tightness, and shortness of breath. He spends 50 minutes evaluating the patient, taking her complete history, conducting a detailed examination, and reviewing the patient’s responses to questionnaire tests.
During this session, the doctor identifies that the patient has no suicidal tendencies and discusses the appropriate treatment plans for her anxiety, including prescribing therapy and anti-anxiety medications.
The billing team later uses CPT code 99204 based on three factors: the patient’s complex condition, the advised treatment plan, and the time spent by the doctor.
Evaluating an Acute Complicated Injury
A 35-year-old man arrives with pain in the left shoulder. He also complains about experiencing numbness in his left hand fingers for the past 2 months, despite no known injury. The doctor conducts a detailed examination and notes tenderness in the patient’s left shoulder and decreasing sensation in his left hand and finger.
Suspecting nerve damage, the doctor orders an MRI to confirm the diagnosis and plans to refer the patient to a neurologist for potential surgical intervention. This face-to-face encounter lasts 50 minutes.
Given the complexity of the patient’s condition, the appointment’s timing, and the moderate level of medical decisions, the billing team later uses CPT code 99204 to bill for this E/M service.
CPT Code 99204 – Documentation Requirements
As we said, E/M services are primarily cognitive. Therefore, insurance companies require complete and accurate documentation to evaluate their medical necessity and the levels of medical decision-making. However, this is easier said than done.
E/M services require healthcare providers to document their entire thought process and clinical judgment. Want to avoid unnecessary scrutiny or payment delays? Follow these simple documentation requirements for CPT code 99204 to receive compensation for your hard work.
Medical History & Present Symptoms
This is the most important part of the documentation process, helping insurance companies evaluate the medical necessity of the patient-doctor encounter. It includes recording four key components:
- Chief Complaint (CC)
- History of Present Illness (HPI)
- Review of Systems (ROS)
- Past Medical, Family, and Social History (PFSH)
Let us explain each in detail. You should start by recording the primary reason for the patient’s visit, the Chief Complaint (CC). It could be due to an acute injury, chronic illness, or acute illness with systemic symptoms. Then, document the patient’s current symptoms, including their duration, intensity, and other details. This is called the History of Present Illness (HPI).
After that, record information about the patient’s overall health, such as weight loss or gain, fatigue, skin condition, or other factors. This data is usually gathered by a systematic method called Review of Systems (ROS), where a provider asks targeted questions. This step will also help you identify potential areas for further examination.
Finally, complete this section by documenting the patient’s past medical conditions, common family diseases, and lifestyle choices, like tobacco, alcohol, or drug addiction.
Record Examination Details
In the next stage, document the entire process for diagnosing the patient, including all the tests you prescribed or conducted. Keep in mind that the physical examination should align with the problems raised in the History of Present Illness (HPI) and Review of Systems (ROS). In simple words, it should address all the relevant issues.
Document Medical Decision-Making (MDM) Process
Payers also evaluate the appropriateness of an E/M code based on the level of medical decisions. As mentioned in the description section, the AMA has categorized MDM into four levels based on these three factors:
- Number and complexity of addressed problems
- Data reviewed and analyzed
- Risk of complications
Therefore, record everything, from the number and severity of your patient’s condition and the review of test results to the potential associated risks.
Note the Duration
The time spent with the patient is another crucial documentation requirement for CPT code 99204. Note the duration of your encounter, 45 to 59 minutes, with the new patient to justify the use of this code.
Outline the Treatment Plan
Finally, outline the treatment plan you have developed during this encounter. This involves documenting prescriptions, referrals, follow-up care, or any other recommendations for managing the patient’s condition.
Things to Consider While Billing CPT Code 99204
You should consider the following factors when billing for CPT code 99204:
Familiarity with the E/M CPT Codes
This is the most important factor to consider. Familiarity with all E/M codes is essential for accurately reporting and billing each encounter, especially if you work in primary care, internal medicine, or family practice. Each E/M CPT code, including 99204, has specific criteria, such as different levels of medical decision-making and time requirements.
Patient Eligibility
Eligibility is another key element to consider. CPT code 99204 is only applicable to new patients. The AMA has clarified the difference between new and established patients. Therefore, don’t forget to verify that neither you nor any other physician in your group practice has provided professional services to the patient within the past three years.
Complete Documentation
Your documentation must be complete to support the use of CPT code 99204. We have highlighted all the documentation requirements in the previous section. Just keep one more thing in mind. If you spent time coordinating care with other professionals during the encounter, don’t forget to include it in your notes.
Compliance with Payer Guidelines
Payer-specific requirements are another crucial factor. Always review and adhere to the specific guidelines or Local Coverage Determinations (LCDs) of each insurance company to avoid unexpected denials.
Auditing
Initiate or improve your auditing processes for documentation and coding. Regular audits increase compliance with payer-specific and regulatory requirements, reducing errors and the risk of claims denials.
Review Before Submission
Coding mistakes are common, even with significant safety measures. Therefore, double-check the documentation and details of the patient encounter, such as duration, the complexity of the condition, and associated risks, to ensure that you have selected the correct code.
Conclusion
Do you now fully understand the key requirements for using CPT code 99204? This time-based E/M code is specifically for reporting initial office or other outpatient visits that involve recording medically appropriate history, conducting detailed examinations, and making moderate-level decisions. This code reports 45- to 59-minute-long doctor-patient encounters. We have covered all the relevant details, requirements, and restrictions of this CPT code to help you avoid claim denials. However, if a denial is triggered, our denial management services are at your disposal for timely resolution.
