Killer tips for Coding CPT code 99204

We have the Evaluation and Management section in the beginning of the CPT codebook. Some coders will be struggling about the how to meet all the 3 key components for few CPT codes. These  section is used mainly for office or outpatient visits. Before going ahead we should first know about the difference between a new patient and Established patient.
Established patients: received prior professional services from the physician or qualified health care professional or another physician or qualified health care professional in the practice of the exact same specialty and subspecialty in the previous three years (99211-99215)


Killer tips for Coding CPT code 99204
New patients: have not received professional services from the physician or qualified health care professional or any other physician or qualified health care professional in the same practice in the exact same specialty and subspecialty in the previous three years (99201-99205)

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When to code CPT code 99204


So, now we can differentiate between new and established patients, we will learn when to use CPT code 99204.
For coding CPT code 99204, we generally require 3 key components
A comprehensive history
 
A comprehensive Examination
 
Medical decision making of moderate complexity
 
So if an office or outpatient visit meet all the above three 3 key components, we can go ahead use CPT code 99204. The presenting problem is usually is of moderate to high severity in such visits. The physician generally spent 45 minutes in face to face with patient and/or family.
There few services are not included with CPT code 99204.
The services provided in Emergency department (99281-99285).
The services provided in Hospital observation (99217-99223 [99224, 99225, 99226])
Hospital observation or inpatient with same day admission and discharge (99234-99236)

Points to remember for coding CPT code 99204


For CPT code 99204, all three major criteria (history, physical exam and medical decision making) must be met.
For a 99204, the review of systems must include at least 10 systems or body areas..
For CPT code 99204, the past, family and social history must cover all three areas.
For a 99204, the physical exam must cover at least 18 bullets from at least nine systems or body areas. .

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