Can you bill 99204 to Medicare?
Asked by: Prof. Nigel Glover | Last update: October 16, 2025Score: 5/5 (6 votes)
Is CPT code 99204 covered by Medicare?
In the past years, this E/m code has been paid $169.93 by Medicare in 2021.
What is the Medicare allowable rate for 99204?
The reimbursement rate for CPT Code 99204 can vary slightly depending on the region and the specific payer. However, for 2024, the Medicare reimbursement rate for CPT 99204 is approximately $167.10.
What are the criteria for 99204 billing?
For a 99204, all three major criteria (history, physical exam and medical decision making) must be met. A 99214 requires only two of the three major criteria. For a 99204, the review of systems must include at least 10 systems or body areas.
Can you bill Medicare Wellness and Office Visit?
The CMS website states “When you provide an annual wellness visit and a significant, separately identifiable, medically necessary Evaluation and Management (E/M) service, Medicare may pay the additional service. Report the additional CPT code with Modifier-25.
Checking Eligibility, Coding and Billing Medicare
Does Medicare have a deductible for office visits?
Beyond that, Medicare Part B covers 80% of the Medicare-approved cost of medically necessary doctor visits. The individual must pay 20% to the doctor or service provider as coinsurance. The Part B deductible also applies, which is $257 in 2025.
Can you bill 99214 and G0439 together?
Medicare does discourage this and says there is too much 'crossover' between these two preventive services. We usually see a 99213 or 99214 with a G0438 or G0439 to represent the problem management outside the AWV. If you bill G0438/G0439 and a 99397, recognize that Medicare does not cover the 99397.
What is an example of a 99204 visit?
If you are still not feeling confident in knowing what CPT code 99204 means, consider the following patient description example. A new adult patient visiting an office, or outpatient facility, for an acute illness or injury that requires medical management. The patient may even be eligible for surgical treatment.
When to use 99024?
99024 - Postoperative follow-up visit, normally included in the surgical package, to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) related to the original procedure. Applies to surgeries with 90 and 10 day global periods.
What is the difference between code 99204 and 99205?
Code 99204 requires a minimum of 45 minutes of face-to-face time with the patient and Code 99205 requires a minimum of 60 minutes face-to-face time with the patient. For both services, at least 50% of the face-to-face time must be spent providing counseling and/or coordination of care.
What are the new patient guidelines for Medicare?
Individual who has not received any professional services, Evaluation and Management (E/M) service or other face-to-face service (e.g., surgical procedure) from the same physician or physician group practice (same physician specialty) within the previous 3 years.
Can a physician assistant bill 99204?
If you are talking a level 4 new patient visit 99204, then it can only be billed if the patient has not been seen in your practice by any of your physicians in the last 3 years and meets level 4 criteria.
Will Medicare allow telehealth in 2025?
Through March 31, 2025, you can get telehealth services at any location in the U.S., including your home. Starting April 1, 2025, you must be in an office or medical facility located in a rural area (in the U.S.) for most telehealth services.
What is the Medicare fee schedule?
A fee schedule is a complete listing of fees used by Medicare to pay doctors or other providers/suppliers. This comprehensive listing of fee maximums is used to reimburse a physician and/or other providers on a fee-for-service basis.
Can you bill CPT II codes to Medicare?
Beginning June 1, 2021, we will add CPT II codes to the fee schedule at a price of $0.01, which will allow billing of these codes while avoiding claim denial due to a “non-payable code”.
Does Medicare pay for 99204?
The Medicare reimbursement rate for CPT code 99204 in 2024 is set at $167.10. Code 99204 is the most popular code for billing new patients seen in the office, with internists choosing it for 49.61% of these types of encounters.
What are the rules for 99204?
CPT code 99204: New patient office visit, minimum 45 minutes
When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded. As a prescriber, you can bill insurance according to time or medical decision-making (MDM).
What is the difference between 92004 and 99204?
With the proper chart documentation in place, the encounter can most often be coded as 99204 (E/M code) rather than 92004 (eye code). The national average differential between the two is $16.13, favoring the E/M code (Table 2). Over time, this difference can add up for any size practice.
What is the CPT code 99214 for Medicare billing?
CPT® code 99214: Established patient office visit, 30-39 minutes | American Medical Association.
Will Medicare pay for two different doctor visits on the same day?
The para states that as for all other E/M services except where expressly noted, the Medicare Administrative Contractors (MACs) may not pay two E/M office visits billed by a physician (or physician of the same specialty from the same group practice) for the same beneficiary on the same day unless the physician ...
Who can bill for Medicare annual wellness visit?
Medicare Part B covers the Annual Wellness Visit (AWV) if it is furnished by a: • Physician (doctor of medicine or osteopathic medicine) • Physician assistant • Nurse practitioner • Clinical nurse specialist • Medical professional (including a health educator, a registered dietitian, nutrition professional, or other ...
Do Medicare wellness visits need to be 12 months apart?
Visits must be at least 11 months apart
“In order for Medicare to pay for annual wellness visits, at least 11 full months must have elapsed,” Dr. Candler said.