99204 CPT Codes description and guidelines 2023

Medical billing and coding professionals rely heavily on the use of CPT codes to accurately report medical procedures and services. One of the most frequently used codes is the 99204 code, which provides a specific description of a particular medical procedure. In this article, we will delve into the details of the 99204 CPT code, including its purpose, its prerequisites, and the documentation requirements necessary to use it effectively. By the end of the article, you will have a comprehensive understanding of this crucial CPT code and its role in the medical billing and coding process.

What is a 99204 CPT code?

When a healthcare professional, such as a physician or non-physician practitioner, provides a new patient with an evaluation and management (E/M) service in an outpatient setting, they use the 99204 CPT code to bill for their services. It is essential to note that this code requires a comprehensive examination, a detailed history, and a moderate level of medical decision-making. This means that the healthcare professional will need to gather all the necessary information and assess the patient’s condition to determine the best treatment plan.

Requirements for 99204 CPT code

In order to bill for a 99204 code, several requirements must be met:

  1. New Patient: The patient must be new to the healthcare provider or practice. If the patient has received any professional services from the provider within the past three years, they are considered an established patient.
  2. Detailed History: The healthcare provider must obtain a detailed history of the patient’s chief complaint, present illness, and past medical, family, and social history. This includes a review of systems and a comprehensive past medical history.
  3. Comprehensive Examination: A comprehensive examination of the patient must be performed, including an evaluation of body systems related to the chief complaint. This may include a detailed examination of the affected body areas or organ systems.
  4. Moderate Medical Decision-Making: The healthcare provider must demonstrate a moderate level of medical decision-making, which includes considering the patient’s history, examination findings, and medical complexity. This may involve ordering and reviewing diagnostic tests, developing a tentative diagnosis, and initiating or adjusting a treatment plan.

Documentation guidelines

In order to support a 99204 CPT code, proper documentation is crucial. The documentation should accurately reflect the patient’s history, examination, and medical decision-making. Here are some key points to keep in mind:

  • The documentation should clearly state that the patient is a new patient.
  • The history should be detailed and include relevant information about the patient’s chief complaint, present illness, past medical, family, and social history.
  • The examination should be comprehensive and thoroughly document the evaluation of body systems related to the chief complaint.
  • The medical decision-making should be well-documented, including the thought process behind the diagnosis and treatment plan.
  • All documentation should be legible, dated, and signed by the healthcare provider.


The 99204 CPT code is an important code used for billing evaluation and management services for new patients. It requires a detailed history, a comprehensive examination, and a moderate level of medical decision-making. Proper documentation is essential to support this code and ensure accurate billing. By understanding the requirements and documentation guidelines, healthcare providers can effectively utilize the 99204 CPT code in their medical billing and coding processes.

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