99204

Office or other outpatient visit for the evaluation and management of a new patient, moderate complexity

CPT code 99204 describes an office or other outpatient visit for the evaluation and management of a new patient. This level of service requires a medically appropriate history and/or examination, and a moderate level of medical decision making (MDM). When using time as the basis for code selection, 45-59 minutes of total time must be spent on the date of the encounter. This total time includes both face-to-face and non-face-to-face time personally spent by the physician or other qualified healthcare professional on the date of the encounter, such as preparing to see the patient, performing the service, ordering and reviewing tests, counseling and educating, and documenting in the medical record.

Clinical Indications

  • New patient presenting with an undiagnosed new problem with an uncertain prognosis requiring extensive workup and management.
  • Initial evaluation of a new patient with an acute illness presenting with systemic symptoms (e.g., acute pyelonephritis, pneumonia with hypoxia).
  • Management of a new patient presenting with an acute complicated injury (e.g., a significant laceration requiring complex repair, moderate sprain with suspicion of fracture requiring further workup).
  • New patient requiring prescription drug management for a new or exacerbating condition.
  • Evaluation of a new patient whose diagnosis or treatment is significantly limited by social determinants of health, adding complexity to care planning.
  • Patients requiring extensive review of prior medical records from external sources and/or discussion with an independent historian to establish a treatment plan.

Procedure Steps

  1. Obtain a medically appropriate history (e.g., comprehensive or focused, as determined by the nature of the presenting problem).
  2. Perform a medically appropriate examination (e.g., comprehensive or focused, as determined by the nature of the presenting problem).
  3. Formulate a diagnosis or differential diagnoses based on clinical findings and available data.
  4. Order and review diagnostic tests (e.g., laboratory, imaging, physiological studies) to further investigate the patient's condition or monitor response to therapy.
  5. Develop and document a management plan, which may include initiation or adjustment of medications, referrals to specialists, or discussion of surgical options.
  6. Provide counseling and education to the patient and/or family regarding their condition, treatment options, expected outcomes, and necessary lifestyle modifications.
  7. Coordinate care with other healthcare professionals or resources as needed (e.g., home health, social services).
  8. Document all clinical findings, medical decision making, and total time spent (if using time for code selection) in the patient's medical record.

Coding Guidelines

  • **New Patient Definition**: A 'new patient' is one who has not received any professional services from the physician or other qualified healthcare professional, or another physician or other qualified healthcare professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.
  • **Basis for Code Selection**: For office or other outpatient E/M services (99202-99215), code selection is based on either the level of medical decision making (MDM) or the total time spent on the date of the encounter. The provider should choose the method that results in the highest-level code supported by documentation.
  • **Medical Decision Making (MDM)**: To qualify for a moderate MDM level, at least two of the three MDM elements must be met: (1) moderate number and complexity of problems addressed, (2) moderate amount and/or complexity of data to be reviewed and analyzed, and (3) moderate risk of complications and/or morbidity or mortality of patient management.
  • **Time Documentation**: If time is used for code selection, the total time spent by the physician or QHP on the date of the encounter must be clearly documented. This includes both face-to-face and non-face-to-face activities (e.g., preparing to see the patient, reviewing tests, counseling, coordinating care, documenting).
  • **Documentation Requirements**: The medical record must clearly support the level of service billed, detailing the history, examination findings, assessment, plan, and complexity of MDM or total time spent.
  • **Bundling**: Other separately identifiable services performed during the same encounter (e.g., minor procedures, vaccinations) may be billed in addition to 99204, if appropriate and documented. Modifier 25 may be required when an E/M service is performed on the same day as a minor procedure by the same provider.

Associated ICD-10 Codes