The world of medical billing begins with 99204 CPT code. It is the code that is used to document new patient visits. This code is used for visits that last for 45-59 minutes. This code needs a detailed medical history and a moderate level of decision making.
In this blog, we will go through the CPT code 99204. But first, let’s take a stroll through Current Procedural Codes. So, let's start!
What are Current Procedural Codes?
Current Procedural Codes fall into three main groups that are Category 1, Category 2 and Category 3. Category 1 includes 99204 CPT code reimbursement for common services. Category 2 includes additional tracking codes and category 3 is for new tech and services.
The Role of CPT Codes in Healthcare
Medical billing CPT codes are vital in the healthcare industry. They help providers and payers talk about services they render. This helps in the smooth functioning of billing and payments.
What is CPT Code 99204?
99204 CPT code is used for new patient visits. It needs a detailed history, physical examination, and moderate decision-making. This code is very important for documenting patient care, offering flexibility and good care quality.
This code is used for meetings that last for 45-59 minutes. It handles moderate to high severity problems. This includes counselling, care coordination, and diagnostic tests. The work RVU for CPT code 99204 is 2, with malpractice RVU at 0.22.
Facility RVU is 1.01, and non-facility RVU is 2.00. This totals 3.66 for facility and 4.65 for non-facility services.
Key Pointers for 99204 CPT Code
- CPT code 99204 is important for billing and payment in healthcare.
- Healthcare providers need to stay updated with the latest CPT codes, like 99204, to avoid payment issues.
- The CPT code set is divided into three main categories from which category 1 codes are the most commonly used for payment.
| Evaluation & Management Codes | Reimbursement Rates (2022) | Reimbursement Rates (2023) |
|---|---|---|
| 99202 | $80.91 | $72.86 |
| 99203 | $124.39 | $112.84 |
| 99204 (Moderate MDM) | $185.26 | $167.40 |
| 99204 (High MDM) | $244.99 | $220.95 |
Key Components of a New Level 4
Healthcare providers document several important elements for a level 4 new patient visit (99204 CPT code). It includes detailed patient history, an extensive physical exam, and good decision making. These steps help address the codes ensuring correct reimbursement.
Comprehensive Patient History Requirements
A level 4 new patient visit needs a detailed patient history that includes the patient’s current ailment, past health record, family history, social background and an extensive review of systems. Providers should document this information with absolute clarity to showcase the complexity of patient visits.
Physical Examination Standards
The Physical Examination for a level 4 visit should inspect multiple organ systems or a complex single system. Providers must go through at least 18 elements from 9 body areas or systems. This makes sure a complete assessment of the patient’s health.
Medical Decision Making
Medical decision-making part of a level 4 visit is complex. Healthcare providers must weigh various diagnoses, management options, and data review. They also consider the risk of the patient’s condition and treatment plan.
A detailed documentation of these factors is important to justify 99204 CPT code.
By taking care of these elements, healthcare providers ensure accurate coding and fair payment for a level 4 new patient visit. It is very important to pay close attention to detail and document everything thoroughly. This shows the need and complexity of the service.
Proper documentation of these codes is essential for healthcare providers to ensure accurate reimbursement and justify the use of 99204 CPT code.
Distinguishing Between New & Established Patients
Categorizing the patients accurately as new or established is important for coding accuracy. The three-year rule helps determine patient status. A patient is someone who has not seen a doctor in the same field for the last three years.
For new patients, providers use the 99204 CPT code and for established ones they use 99214 CPT code. The payment for these codes also differs a lot, which makes accuracy even more important.
Group Practice Considerations
The three-year rule applies to the whole group of doctors. If the patient has seen any other doctor of the same group in the past three years, they are considered as established. This is also true if the patient is visiting a specific doctor of the same group for the first time.
- There are some exceptions too like some healthcare providers need obstetric providers to bill the first prenatal visits as new patient visits.
- Knowledge about provider taxonomy and specialty distinguishes new patients and established patients.
- If a claim is denied, checking patient history and provider specialty taxonomy helps with an appeal.
Accurate coding and documentation are crucial for right payment and health of a medical practice. Understanding the differences between new and old patients helps doctors improve.
Medical Documentation Requirements for 99204
When billing CPT 99204, proper documentation is very important. The documentation must express the medical need for the visit and the level of service given.
While billing for CPT 99204, the healthcare practitioner’s documentation must include the following elements:
- Extensive physical examination findings, with at least two bullets for each of the nine organ systems.
- A comprehensive documentation of the medical decision-making process that meets the criteria for moderate complexity. This includes having at least two out of three factors: problem points, data points and moderate risk.
By maintaining a detailed record that matches the 99204 CPT code description, healthcare providers ensure accurate medical billing that helps avoid reimbursement issues or denials. Proper documentation supports the level of service and protects against audits and disputes.
Common Challenges & Biling Errors with CPT Code 99204
Maintaining CPT code 99204 for new patient visits can be tricky. A big reason for errors is not documenting well enough. This causes errors and affects how much money you get back as reimbursement.
It is important to keep track of how much time you spend with the patients. This allows you to avoid mistakes that will lead your practice towards audits that may result to revenue loss for your practice.
How Outsourcing Helps
The complexity of medical billing never tends to end and with the frequent changes in coding and billing guidelines, it only becomes difficult for practitioners to keep up.
This is where medical billing companies such as Unify healthcare Services help practitioners to manage their billing and coding requirements. We have a well-established name in the field of medical billing and coding.
Our team of experienced and dedicated professionals take care of all your medical billing and coding requirements. We are always updated about the latest billing and coding guidelines which ensure accuracy of claims before filing them for reimbursement. Unify healthcare envisions making medical billing easy for every healthcare practice so the providers can focus solely on their core expertise.
This increases the footfall of your healthcare practice which ultimately increases the revenue of your organization.
