99204

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

An office or other outpatient visit for the evaluation and management of a new patient. This service requires a medically appropriate history and/or examination and a **moderate level of medical decision making (MDM)**. When selecting the code based on total time on the date of the encounter, **45-59 minutes** of total time must be spent by the physician or other qualified healthcare professional (QHP). A moderate MDM level is characterized by addressing multiple problems, with at least two stable chronic illnesses, or one chronic illness with exacerbation, progression, or side effects of treatment, or an undiagnosed new problem with uncertain prognosis, or acute illness with systemic symptoms, or an acute complicated injury. Data review and analysis typically involves reviewing prior external notes, ordering and reviewing diagnostic tests, and/or an independent interpretation of tests. The risk of complications from patient management is moderate, often involving prescription drug management, or decisions regarding minor surgery with identified risk factors, or major surgery without identified risk factors.

Clinical Indications

  • New patient presenting with new onset symptoms requiring moderate diagnostic workup and management.
  • Initial evaluation of an undiagnosed problem with an uncertain prognosis that necessitates moderate complexity decision making.
  • First-time evaluation of an acute illness with systemic symptoms (e.g., pyelonephritis, pneumonia not requiring hospitalization).
  • Initial assessment of a chronic condition (e.g., newly diagnosed diabetes, complex hypertension) requiring moderate management plans, lab interpretation, and patient education.
  • Evaluation of an acute complicated injury (e.g., moderate sprain with associated nerve impingement, initial evaluation of fracture not requiring immediate surgery).
  • Patients requiring moderate complexity in data review, such as reviewing external medical records, ordering advanced imaging, and interpreting lab results to formulate a treatment plan.

Procedure Steps

  1. Obtain a comprehensive or problem-focused history of present illness, review of systems, and past, family, and social history appropriate to the patient's condition.
  2. Perform a medically appropriate physical examination, either problem-focused or comprehensive, as indicated by the nature of the presenting problems.
  3. Evaluate and address the patient's presenting problems, which typically involve moderate complexity based on the number and nature of issues.
  4. Engage in medical decision making, which includes considering differential diagnoses, assessing risk, and determining the appropriate course of action.
  5. Order and interpret diagnostic tests (e.g., laboratory tests, imaging studies) as necessary to aid in diagnosis and management.
  6. Develop and discuss a management plan, including prescribing medications, ordering therapies, making referrals, and providing patient education and counseling.
  7. Coordinate care with other healthcare professionals or facilities if indicated.
  8. Document the patient encounter thoroughly, including history, examination findings, assessment, plan, and total time spent on the date of the encounter if time is used for code selection.

Coding Guidelines

  • Code selection for E/M services (99202-99215) for office or other outpatient visits is based on either the level of Medical Decision Making (MDM) or the total time spent on the date of the encounter.
  • A 'new patient' is defined as one who has not received any professional services from the physician or another physician/QHP of the exact same specialty and subspecialty in the same group practice within the past three years.
  • The total time includes both face-to-face and non-face-to-face time personally spent by the physician or other QHP on the date of the encounter, directly related to the patient's care. This includes activities such as preparing to see the patient, obtaining/reviewing history, performing medically appropriate examination, counseling, ordering tests, referring, and documenting.
  • Documentation must clearly support the chosen MDM level or the total time spent. For MDM, documentation should reflect the number and complexity of problems, the amount and complexity of data reviewed, and the risk of complications.
  • Do not report services separately that are inherent to the E/M service (e.g., blood pressure measurement, basic vital signs).
  • If a significant, separately identifiable E/M service is performed on the same day as a minor surgical procedure (e.g., minor laceration repair), modifier -25 may be appended to the E/M code (e.g., 99204-25).
  • This code has a global period of 'XXX' meaning the global concept does not apply. Other services performed on the same day may have their own global periods.

Associated ICD-10 Codes