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How to use CPT code 99204

Code 99204 represents a new patient appointment that’s at least 45 minutes in duration.

The 99204 code is an E/M code used by prescribing providers. For other E/M codes, visit this overview.

CPT code 99204 description

Code 99204 represents a new patient appointment that’s at least 45 minutes in duration. It’s a prescriber code, which means it’s most commonly used by psychiatrists or nurse practitioners. 

This is is how the American Medical Association defines 99204 in the official CPT codebook:

CPT code 99204: New patient office visit, minimum 45 minutes

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. 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). Make sure to include sufficient documentation to support the method you choose.

If you spent at least 45 minutes with a client but the case was especially complex or high risk, or involved reviewing or analyzing a lot of data, you may use a higher CPT code, including 99205 (high MDM).

It’s important to use the code that most accurately reflects the time you spent with the patient to treat their condition, and ensure that documentation for the session supports the chosen code. 

99204 vs 99214: New patient vs. existing patient

If you’re treating an existing patient, you should use 99214 instead. A new patient is someone you have not seen in the last three years.

CPT code 99204 time frame

CPT code 99204 is a new patient appointment of at least 45 minutes with moderate MDM. Other time frames for a new patient should be coded with [99202] (at least 15 minutes), [99203] (at least 30 minutes), or [99205] (at least 60 minutes).

CPT code 99204 documentation

Documentation for 99204 is essentially the same as other E/M codes, but geared toward a new patient.

  • Medically appropriate history: Document relevant information about the patient’s presenting complaint, medical history, and any other important factors.
  • Medically appropriate examination: Perform and document an evaluation that’s appropriate for the patient’s presenting complaint.
  • Moderate complexity medical decision making: Make a judgment about the patient’s diagnosis, create a care plan, and prescribe appropriate treatments or interventions.
  • If you are billing based on time, include start/stop timers.


Here’s a new patient example note:

Patient Name: Rose Jackson

Date of Service: 03/27/2023

Patient DOB: 3/30/1997

Appointment Time: 2:30pm-3:15pm

Place of Service: Patient was located at their home at 123 Main St Anywhere US 12345 

Provider was located at their office: 456 Storybook Ln Hollywood CA 96852 

This session was provided via a HIPAA compliant interactive audio/video platform. The patient consented to this telemedicine encounter.

The total time I spent caring for this patient today was 55 minutes which included: interviewing the client, documenting, reviewing the patient's responses to questionnaires, discussing treatment plans, coordinating care, prescription management and counseling the client on managing her mental health.

Subjective

Chief Complaint: Patient presents with anxiety and panic attacks, occurring 3-4 times per week.

HPI: 27-year-old female reports experiencing uncontrolled anxiety and recurrent panic attacks for the past 4 months. She describes palpitations, shortness of breath, and chest tightness during these episodes. Patient also reports difficulty concentrating and frequent crying spells. Denies any suicidal ideation.

ROS:

  • General: No weight loss, occasional fatigue.
  • Cardiovascular: Palpitations during panic attacks, no chest pain outside of these episodes.
  • Respiratory: No chronic cough or wheezing.

PMH/PSH:

  • Past medical history: Anxiety, treated with counseling in the past.
  • Past surgical history: None.

Medications: None currently.

Objective

Allergies: No known drug allergies.

Substance Use Assessment: Denies tobacco and drug use, occasional alcohol use (1-2 drinks per week).

MSE:

  • Appearance: Clean and appropriately dressed.
  • Behavior: Anxious but cooperative.
  • Speech: Slightly rapid, coherent.
  • Mood: Anxious.
  • Affect: Congruent with mood, appropriate to context.
  • Thought Process: Logical, goal-directed.
  • Thought Content: No evidence of hallucinations or delusions.
  • Cognition: Fully oriented to person, place, and time.
  • Insight/Judgment: Insight limited, judgment intact.

Assessment

  • Diagnosis: Panic Disorder, Generalized Anxiety Disorder (severe).
  • Plan: Initiate treatment with Sertraline 25 mg daily and provide a prescription for Clonazepam 0.5 mg PRN for acute episodes.
  • Referral: Recommend therapy with a licensed therapist for cognitive-behavioral therapy (CBT).
  • Prescription: Sertraline 25 mg daily, Clonazepam 0.5 mg PRN.

PDMP Check: The state’s PDMP was reviewed as required, and no concerning patterns were identified.

Risks and Benefits of Medication Adherence: The patient was counseled on the risks and benefits of adhering to prescribed medications, including potential side effects and the importance of consistent use for efficacy.

Time spent: 45 minutes face-to-face.

Electronically signed by:

[Provider name, Credentials, Date signed]

_____________________________________________________________________________________________

Rationale information is not required in your note; it is provided for educational purposes only.    

Rationale and How the CPT Codes Were Selected:

Number and Complexity of Problems Addressed: Moderate, 1 chronic illness with exacerbation

Data Reviewed/Analyzed: none

Risk: Moderate: Moderate, prescription drug management

Rationale: The client displays Moderate number & complexity of problems with one chronic illness with an exacerbation, No data reviewed, and Moderate risk for no prescription management.

Level of MDM: Moderate

CPT Codes Selected: 99204

CPT code 99204 reimbursement rates

Reimbursement rates for sessions billed with 99204 will vary depending on factors like the specific payer contract, your geographic location, and type of therapy license. Headway providers can check the portal for rates with each insurance provider.

Find out your rates with Headway

This document is intended for educational purposes only. It is designed to facilitate compliance with payer requirements and applicable law, but please note that the applicable laws and requirements vary from payer to payer and state to state. Please check with your legal counsel or state licensing board for specific requirements.

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