billing CPT CODE 99204 - WHEN TO USE

We will be covering the 99204 CPT code. In 2003 it was selected 30% of the time for the new patient encounter.....which means just about 65% of patients fit into the 99203 or 99204 zone. My guess is that by the time we are done, you will be using 99204 much more than not.

So what is a 99204?

99204 requires these 3 components

1. A "Comprehensive" History
2. A "Comprehensive" Examination
3. Medical Decision Making of "Moderate" Complexity

Once again the definition of Moderate and Comprehensive are key here.

Moderate Complexity Decision Making is often audited and requires:

A. Multiple Diagnoses or Management Options. AMA doesn't list the exact number here but E and M University has a good wrap up 

The take home is that new problems with additional work up gets a maximum of 4 problem points. If it is a new problem with no further work up it is 3 points.

You can feel pretty confident  billing 99204 here if you have 3 points here AND

B. Amount and/or complexity of data reviewed has to be moderate as well. 
In this case you would need 3 data points reviewed. Ordering clinical lab tests counts as 1 point. So does ordering a radiology test, the same with EKG.
Discussing the results with a physician gives you a measly one point as well. But independent review of the specimen, image or tracing gives you 2 points......

So if you looked at the film, document that you looked at the film....or EKG.....
Review and summation of Old Records ALSO gives you 2 points.......

You can consider yourself getting warm here if you have 3 data points here AND 3 problem points.......

C. Moderate Risk of Complications, Morbidity or Mortality.....Well, what does that mean?

You can turn to the "Table of Risk!"
This basically indicates that you have one thing of 3 categories......

Category A-Presenting Problems
One or more chronic illnesses with mild exacerbation
Two or more stable chronic illnesses (HTN and Hyperlipidemia)
One Undiagnosed New problem
Acute Illness with Systemic Symptoms

Category B-Diagnostic Procedures
Stress Test or Fetal Stress test
Diagnostic Endoscopies
Deep Needle or Incisional Biopsies
Cardiac Cath
Fluid removal from Body Cavity

Category C-Management Options Selected
Minor surgery
Elective Major Surgery
Prescribing Medicines
IV fluids
Closed treatment of a fracture

So, you need one of each category to qualify Risk as a moderate data point

Listen, this system is complicated here.....My gut tells me that you should not count on using Risk as 1 of your 2 required points to qualify MDM as moderate complexity.

My take home on MDM is-Always review your own data, Always review old records,  Always document new problems and demonstrate your work up of them......If you do these things you will likely qualify for moderate MDM

Now that's over, let's look at a Comprehensive Exam

Comprehensive is defined as 
1. "A general multisystem examination"
2. " A complete examination of a single organ system"

Organ systems are:
Each Extremity, I repeat EACH Extremity
Ear, Nose,Throat and Mouth

If you set up a template of your exam as such, you will do well in documenting these events. The take home here is that to be complete you would need 2 bullets for each of the 9 systems.......Ah silly coders, they have to be so precise in defining they really know what complete means?

I go over bullets and the exam in prior posts 

This is a gimmee here. Anyone would do this for a new patient......Anyone......Count Complete physical as one of the 2 Categories filled

Complete History. This bugger is considered the Highest Level of History. Which means often people try but fail at performing this.

This history includes:
1. Chief Complaint
2. "Extended" HPI
3. Review of systems related to the problems in the HPI PLUS all other systems
4. COMPLETE Family, Social and Past Medical and Past Surgical History

I will go through each in detail, but suffice to should be doing these things for ALL new patients if you want to code a 99204.....I actually do this for ALL of my new patients....I will explain why shortly...

The big question here is likely to be What is a COMPLETE PM/PS/Soc/FamHx (PFSHx)......One thing it isn't is NonContributory.......It is at a minimum-Parents, Siblings AND Children! I do grandparents too!

This includes Medicines and Allergies! I repeat, this includes medicines and allergies....

I plan on covering this in another post, but just keep these tips in mind.
Is the patient married? Are they employed? Have they had education? Do they have exposures? Sex? Drugs? Rock and Roll? 

Remember, nearly all outpatient codes require some elements of this here. So it is just good sense to do this at EVERY encounter.....

And most importantly, the PFSHx can be taken by another person, OR EVEN a Form......

What does this look like in real time? 

Initial visit for a 59 year old woman with HTN, Obesity, OA. She has a complaint of palpitations with some occasional dizziness. Her PMSFHx includes TAHBSO for DUB 15 years ago. She has not been seen for 5 years.

Modifiers and Modifier Indicators for CPT 99204

The AMA CPT Manual defines modifiers that may be appended to HCPCS/CPT codes to provide additional information about the services rendered. Modifiers may be appended to HCPCS/CPT codes only if the clinical circumstances justify the use of the modifier. It is very important that our providers bill using the appropriate CPT/HCPCS and Modifiers. For example, when billing for separate identifiable services you must bill with the modifiers listed below in order to be eligible for reimbursement.

Modifier -25: Significant, separately identifiable Evaluation/Management by the Same Provider on the Same Date of Service of the Other Procedure or Service.

• May be appended to an evaluation and management (E&M) CPT code to indicate that the E&M service is significant and separately identifiable from other services reported on the same date of service.

• The E&M service may be related to the same or different diagnosis as the other procedure(s).

• Modifier -25 may be appended to E&M services reported with minor surgical procedures or procedures not covered by global surgery rules. Since minor surgical procedures and global procedures include preprocedure, intra-procedure, and post-procedure work inherent in the procedure, the provider should not report an E&M service for this work. 

Code 99204 Office or other outpatient visit for the E&M of a new patient 27814 Open treatment of bimalleolar ankle fracture (e.g. lateral and medial malleoli, or lateral and posterior malleoli, or medial and posterior malleoli), includes internal fixation, when performed.



1 comment:

Kelly Vickers said...

I thought that as of the first of this year 99204 had been eliminated. It's not listed at all in our new copy of "Medical Fees in the United States 2010." Are you still using it successfully?

Medical Billing Popular Articles