What are the requirements for a 99204 office visit?
Asked by: Zoe Kuphal Sr. | Last update: January 25, 2026Score: 4.6/5 (36 votes)
What are the criteria for a 99204 visit?
99204 CPT code is for new patient office visits. It requires a detailed history, physical exam, and moderate medical decision-making. This code is key for documenting patient care, offering flexibility in time and care quality.
What is allowable for 99204?
Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making.
What is the criteria for 99204 in 2024?
Criteria to code for 99204 in 2024 is (again, with emphasis on MDM and service time): A moderate level of medical decision-making. 45-59 minutes of patient visit time. A comprehensive medical history/patient examination.
What is considered a new patient office visit?
Medicare has stated that a patient is a new patient if no face-to-face service was reported in the last three years. The group practice and specialty distinctions still apply, but “professional service” is limited to face-to-face encounters.
What is a level 4 office / outpatient visit in medical coding? 99214 & 99204 explained.
What is the 3 year rule for new patients?
The rule states that a patient is considered established if they have received face-to-face services from that provider or any other provider of the same specialty and same practice within the last three years.
What is considered a medical office visit?
An office visit is any direct personal exchange between an ambulatory patient and a physician or members of their staff for the purpose of seeking care and rendering health services.
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.
How many years of absence must pass before a patient is considered a new patient again?
Three-year rule: The general rule to determine if a patient is new” is that a previous, face-to-face service (if any) must have occurred at least three years from the date of service.
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.
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 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 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.
What determines the level of an office visit?
Medical decision making drives the level of office visit
The medical decision-making portion of evaluation and management guidelines is what ultimately determines the level billed. Higher complexity in decision making justifies higher levels.
What is the age limit for CPT code 99204?
No, CPT codes 99204 and 99214 will not have age restrictions.
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 qualifies as a new patient visit?
According to CPT, a new patient is a patient who has not been seen by that physician or another physician or other qualified health care professional of the same specialty in the same group practice in the past three years.
Can you bill an office visit with a cast application?
A charge for procedure codes 29000-29590 is allowed only when the casting or strapping is a replacement procedure used during the period of follow-up care. The charge for an office visit is allowed only if significant identifiable further services are provided at the time of the cast application or strapping.
Does Medicare pay for 99204?
In the past years, this E/m code has been paid $169.93 by Medicare in 2021.
How much does a laryngoscopy cost without insurance?
How Much Does a Diagnostic Laryngoscopy (in office) Cost? On MDsave, the cost of a Diagnostic Laryngoscopy (in office) ranges from $194 to $297.
Can a chiropractor bill 99204?
Chiropractic Manipulation with Visit
A level 4 or 5 E/M (99204, 99205, 99214, 99215) will be denied as provider liability because these levels would require significant additional work, and it is seldom appropriate to bill both.
Does insurance pay for office visits?
What does health insurance cover? If a service is covered, it means your health plan will pay for some or all of the cost. Covered services typically include regular office visits with your doctor, tests, urgent and emergency care, hospital stays, prescription drugs, medical equipment and more.
What is the difference between 99204 and 99214?
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. A 99214 requires a review of only two.