CPT Code 99204: New Patient Office or Other Outpatient Services, Level 4 - Chirotouch
February 28, 2024 by ChiroTouch Team Article Billing, Coding
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In this quick reference guide to CPT code 99203, we answer frequently asked questions from our community of chiropractors. Follow us for other articles in our ongoing series, courtesy of ChiroTouch, the cloud-based EHR designed specifically for chiropractors.

About CPT Code 99204: Initial Evaluation and Management of a New Patient, Comprehensive, Moderate Medical Decision-Making, Moderate to High Severity

CPT code 99204 pertains to a comprehensive initial evaluation and management (E/M) service for new patients, requiring a moderately high level of complexity. Guidelines for this code include four components:

  • Comprehensive history-taking. This involves gathering extensive information about the patient’s medical history, including past illnesses, family history, social history, and review of systems.
  • Comprehensive examination. A thorough physical examination covering all relevant body systems and addressing the patient’s presenting problems.
  • Medical decision-making of moderate complexity. Making decisions about diagnosis, treatment plan, and prognosis based on the comprehensive history and examination, including ordering tests and considering multiple diagnoses or treatment options.
  • Coordination of care. If applicable, this involves coordinating care with other healthcare providers or agencies involved in the patient’s management.

The average visit billed under 99204 runs about 45 minutes, but time shouldn’t be your primary criteria for billing this code; complexity takes precedence.

Category or Type of Service

CPT code 99204 falls under the category of Evaluation and Management (E/M) services. This code represents a level 4 E/M service for new patients, indicating a comprehensive initial encounter with higher complexity.

Billing Interval

Code 99204 is typically billed per encounter. This code is for visits with a higher level of complexity, typically lasting from 45-59 minutes. Again, however, complexity is more important than time spent in deciding between one service level and another.

When Should Chiropractors Use This Code?

Chiropractors should use CPT code 99204 for comprehensive initial evaluations of new patients.

This includes situations where:

  • Extensive history-taking is necessary to understand the patient’s medical background thoroughly.
  • A comprehensive physical examination is required to assess the patient’s current health status comprehensively.
  • Moderate complexity medical decision-making is involved in determining the diagnosis, treatment plan, and prognosis based on the comprehensive assessment.

When deciding between different E/M codes, the complexity of care provided should be considered first, and time spent with the patient second.

When Should Chiropractors Not Use This Code?

Chiropractors should avoid using CPT code 99204 in the following scenarios:

  • For established patients. This code is specifically for new patient encounters. Established patients should be billed using appropriate E/M codes based on the complexity of their visit.
  • Routine follow-up visits. Routine follow-up visits typically do not require the extensive history-taking, examination, and decision-making associated with a comprehensive initial evaluation.
  • Chiropractic manipulative treatment (CMT) sessions. CMT sessions are billed separately from E/M services and should not be included in the same encounter unless distinct and separately identifiable.

Which Modifiers Can Be Used With CPT Code 99204?

Modifiers are important tools in ensuring accurate billing. Some modifiers commonly used with CPT code 99204 include:

  • Modifier 25. This modifier indicates that a separate and distinct E/M service was provided on the same day as another procedure or service.
  • Modifier 59. Signifies that a procedure or service was distinct or independent from others performed on the same day.
  • Modifier 95. Indicates that the E/M service was delivered via interactive audio-video telecommunications technology.
  • Modifier GT. Used for telehealth services, particularly if insurers have not adopted modifier 95 universally.

What Are the Billing Guidelines and Documentation Requirements Specific to This Code?

To bill for code 99204 accurately, chiropractors must meet specific billing guidelines and documentation requirements:

  • Frequency of use. Check with each patient’s insurance carrier regarding billing frequency limits for this code and similar E/M codes before submitting claims.
  • New patient status. Ensure that patients billed under this code are new to the practice, as it is not applicable to established patients.
  • Comprehensive encounter. Document a thorough history, examination, and medical decision-making process to justify the level of complexity billed under code 99204.
  • Separate billing. If additional chiropractic services are provided during the same encounter, code 99204 must be billed separately using appropriate modifiers to distinguish between services.

Common Mistakes Made Specific to CPT Code 99204

Avoiding common mistakes can ensure accurate billing under code 99204. Some common errors to avoid:

  • Incorrect patient status. Ensure that patients billed under this code meet the criteria for new patients.
  • Inadequate documentation. Provide detailed and comprehensive documentation to support the level of complexity billed under code 99204.
  • Failure to use appropriate modifiers. Use modifiers when necessary to distinguish between different services provided during the same encounter.

Potential Audit Triggers Specific to This CPT Code

Being aware of potential audit triggers can help chiropractors avoid billing discrepancies and ensure compliance. Audit triggers specific to code 99204 include:

  • Inconsistent use of complexity indicators. Make sure that documentation supports the level of complexity billed under code 99204 to avoid audit discrepancies.
  • Lack of supporting documentation. Provide thorough documentation of the history, examination, and medical decision-making process to justify billing under this code.
  • Misunderstanding payer-specific rules. Review the rules for each payer before billing.

Improving the Accuracy and Efficiency of Billing and Coding Processes

You can enhance the accuracy and efficiency of your billing and coding processes by:

  • Performing regular audits of billing and coding practices.
  • Staying updated on changes to billing and coding regulations.
  • Using modern EHR and practice management software tailored to the needs of chiropractors.

By following these guidelines and best practices, chiropractors can ensure accurate and efficient billing under CPT code 99204, leading to improved practice management and patient care.

ChiroTouch Saves Time and Gets You Paid Faster

To keep your practice running smoothly, you need a streamlined payments and billing system. Meet the ChiroTouch dynamic duo: CT Payments and CT MaxClear.

CT Payments is the modern way to handle patient payments. And for insurance practices, CT MaxClear is an integrated claims processing solution. Together, they help you clear invoices and maintain a smooth cash flow for your practice.

CT Payments and CT MaxClear can make your practice more profitable. Read our blog post Chiropractic Billing: Save 30 Minutes a Day, Get Paid Faster to learn more.

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