When to use 99203 vs 99204?
Asked by: Cali Brown | Last update: August 17, 2025Score: 4.5/5 (27 votes)
What is the difference between 99203 and 99204?
What is the difference between 99203 and 99204? The primary difference lies in the complexity of medical decision-making and the required time. 99204 requires moderate medical decision-making, with a session length of 45 – 59 minutes, indicating a more complex patient visit compared to 99203.
What are the criteria for a 99204 visit?
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.
What are the criteria for 99203 billing?
CPT Code 99203 Requirements
To correctly use CPT code 99203, healthcare providers must meet specific criteria: A low level of medical decision-making. 30-44 minutes of patient encounter time. A comprehensive medical history/patient examination.
What is the difference between 99203 and 99214?
As you look further down the associated codes, you also find important descriptions like 99214 is an office patient for an established patient. One of the fastest ways to get audited and face adjustments and penalties is to bill a 99203 for an established patient who underwent some inpatient hospital procedure.
CPT 99203, 99204 and 99205 || CPT description
What is the difference between 99213 and 99203?
If both doctors work for the same practice, *usually* 99203 can be billed only once per practice, then 99213 for any subsequent visits.
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 considered 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.
How many minutes is 99214?
CPT® code 99214: Established patient office visit, 30-39 minutes | American Medical Association.
What is an example of a 99212 visit?
For instance, examples of a 99212 visit include “Office visit, established patient, 6–year-old with sore throat and headache,” and “Office visit, sore throat, fever and fatigue in a 19–year-old college student, established patient.” As you noted, you could technically document enough history and physical to code for ...
What is allowable for 99204?
CPT Code 99204 Reimbursement Rate (Medicare, 2025): $163.35
In the past years, this E/m code has been paid $169.93 by Medicare in 2021.
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.
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.
What are the qualifications for a 99204?
99204 CPT Code: Definition and Basic Requirements
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. This code covers visits lasting 45-59 minutes.
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.
When to bill 99213 vs 99214?
The primary difference between CPT code 99213 and 99214 lies in the complexity and time involved. While 99213 is for a low level of medical decision-making, 99214 is used for moderate complexity, requiring a higher level of medical decision-making and more extensive history and examination.
What is CPT code 99203 used for?
CPT code 99203 is used for new patient office visits that require a medically appropriate history and/or examination and a low level of medical decision making. The typical time for a CPT code 99203 visit is 30-44 minutes. Proper documentation of the care components is essential to support billing for this code.
What is the time for 99204 billing?
CPT® code 99204: New patient office or other outpatient visit, 45-59 minutes. As the authority on the CPT® code set, the AMA is providing the top-searched codes to help remove obstacles and burdens that interfere with patient care.
When to use modifier 25?
The use of modifier 25 “indicates that documentation is available in the patient's record to support the reported E/M service as significant and separately identifiable,” the council report (PDF) adds.
What is the difference between CPT code 99203 and 99204?
The difference between CPT code 99203 and 99204 lies in the complexity and time. 99203 is used for visits of low complexity (30-44 minutes), while 99204 is used for moderate complexity (45-59 minutes).
How many minutes is a new patient visit?
A new patient office or other outpatient visit, typically 30 minutes, is a visit to a doctor or other healthcare provider that is typically scheduled with an allotted time of 30 minutes. This is different than an emergency room or in-patient visit, as it is a typical office visit with a predefined time allotment.
What is the CMS rule for new patients?
A new patient is one who has not received any professional services, [e.g., E/M service or other face-to-face service (e.g., surgical procedure)] from the physician or physician group practice (same physician specialty) within the previous 3 years.
What is the 57 modifier used for?
CPT modifier 57 may be used to report the decision for surgery for certain codes. This modifier may be used to indicate that an evaluation and management (E/M) service performed on the same day or the day before a major surgery (090 global days) by the surgeon resulted in the decision to perform the procedure.
When should I use 99212?
CPT code 99212 is an evaluation and management code used for established patients in an office or other outpatient setting. It represents a visit that requires a medically appropriate history and/or examination and straightforward medical decision making.
What is a 58 modifier used for?
Modifier 58 is defined as a staged or related procedure performed during the postoperative period of the first procedure by the same physician. A new postoperative period begins when the staged procedure is billed.