The 99204 CPT code is commonly used for office or outpatient medical billing and coding visits. Healthcare providers in USA use it to bill for comprehensive E/M- Evaluation and Management services for new patients as well. However, most of the providers may need help determining when to use this code and how to ensure they are billing correctly. In this article, we’ll dive into everything you need to know about the CPT Code 99204, from its definition to its proper usage in medical claim reimbursement.
What is the 99204 CPT Code?
The 99204 CPT code is a Current Procedural Terminology (CPT) code used for billing for new patients’ comprehensive evaluation and management (E/M) services. It is commonly used in office or outpatient settings and is considered a level four code. The code indicates that a healthcare provider has performed a detailed history, comprehensive examination, and medical decision-making of moderate complexity.
Who Can Use the 99204 CPT Code?
The 99204 CPT code is typically use by healthcare providers, including physicians, nurse practitioners, physician assistants, and other healthcare professionals who are license and qualified to provide E/M services. However, it must be note down that only one healthcare provider can use this code per patient per visit.
When to Use the Procedure 99204?
The 99204 CPT code should be use when a healthcare provider is providing a comprehensive evaluation and management service to a new patient in an office or outpatient setting. To use this code, the provider must perform a detailed history, thorough examination, and medical decision-making of moderate complexity. Additionally, the total time spent with the patient must be at least 45 minutes, with more than half spent on face-to-face evaluation and management services.
What Does the Procedure code 99204 Include?
The 99204 CPT code includes a comprehensive evaluation and management service for new patients. This consists of a detailed history, thorough examination, and medical decision-making of moderate complexity. The healthcare provider must also provide a medical diagnosis, develop a treatment plan, and document the encounter in the patient’s medical record.
How to Ensure Proper Billing for the CPT 99204?
Healthcare providers must follow several guidelines to ensure proper billing for the 99204 CPT code. These include:
- Ensuring that the patient is new and not established patient.
- Performing a detailed history, comprehensive examination, and medical decision-making of moderate complexity.
- Spending at least 45 minutes with the patient, with more than half of that time spent on face-to-face evaluation and management services.
- Documenting the encounter in the patient’s medical record, including the history, examination, medical decision-making, and treatment plan.
- Billing only for services provided and supported by documentation in the medical record.
99204 Fee Schedule for 2023:
For Cpt Code 99204 Fee Schedule and Reimbursement rate in 2023 is as mentioned below,
| HCPCS Code | Time Length | Short Description | Non-Facility Price | Facility Price |
| 99204 | 45-59 Min | Office o/p est mod 45-59 min | $164.40 | $130.99 |
Common FAQs about the Procedure 99204
Ans. No, the Cpt Code 99204 is specifically designe for new patients only. A different CPT code should be used if an established patient requires a comprehensive evaluation and management service.
Ans. Medicare reimbursement rates can vary based on various factors, including geographic location and the individual’s specific plan. However, Medicare reimbursement for the procedure 99204 is generally around $167. This amount may be higher or lower depending on the individual situation.
Ans. Yes, to properly bill for the Cpt 99204 , a healthcare provider must meet all three critical components of the code, which include a detailed history, comprehensive examination, and medical decision-making of moderate complexity.
Conclusion:
In conclusion, the 99204 CPT code is vital for healthcare providers providing comprehensive evaluation and management services to new patients. However, following the guidelines for proper billing is essential to avoid any issues with insurance companies or other payers. By understanding when and how to use this code, healthcare providers can ensure that they accurately bill their services and provide the best care possible for their patients.
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