What is a 99204 for E and M coding?

For a physician, nurse practitioner or physician assistant to be compensated for the services they provide to a patient they must correctly document the events that occurred in the room.  While most medical practitioners document the items, they feel are pertinent CMS has specific criteria that must be documented for the practitioner to bill for each level of service.

The E and M code 99204 is the specific code for a new patient Level 4 patient and is used more frequently than the 99203 but continues to be underutilized and costs medical practices thousands of dollars annually.  The reason that I feel more new patient visits should be coded at a 99204 is due to most patient visits fall into moderate risk complaints which are needed for this level of service. However, the type of practice can have a large impact on the types of presenting complaints.  Also, much like with the 99203, for a new patient visit, most practitioners will complete a comprehensive history and exam at a minimum and in my mind, this should be done. 

The items needed to code for this Level of service are made up of the 3 components of the progress note.  For a new patient, all 3 components must be met.

1.) History-

  1. History of present illness- Duration, location, severity, modifying factors, associated symptoms, context, quality, and timing

  2. Past medical family and social history

  3. Review of Systems – 14 recognized systems

  • Constitutional (e.g., fever, weight loss)

  • Eyes

  • Ears, Nose, Mouth, Throat

  • Cardiovascular

  • Respiratory

  • Gastrointestinal

  • Genitourinary

  • Musculoskeletal

  • Integumentary (skin and/or breast)

  • Neurological

  • Psychiatric

  • Endocrine

  • Hematologic/Lymphatic

  • Allergic/Immunologic 

2.) Exam- The physical exam component is comprised of 

  •  Constitutional (e.g., vital signs, general appearance)

  •  Eyes

  •  Ears, nose, mouth, and throat 

  •  Cardiovascular 

  • Respiratory 

  • Gastrointestinal 

  • Genitourinary 

  • Musculoskeletal 

  •  Skin 

  • Neurologic

  • Psychiatric 

  • Hematologic/lymphatic/immunologic

3.) Medical Decision Making

  1. Diagnosis

  2. Treatment options- Medications, referrals, splints, etc..

  3. Data review – Old records, labs, medical tests, imaging, etc…

  4. Level of Risk – Minimal, low, moderate and high

For a new patient 99204 the following items must be met for each of the three components.

  • History – Four element of HPI, ten systems reviewed, and three PMFSH reviewed

  • Exam- eight systems examined

  • Moderate risk complaint and needs to have either: three diagnoses, three treatment option or three data reviews.

Example: 99204

51 yo male here for a complaint of body aches for 3 days, has used OTC ibuprofen with mild relief.  The patient states the symptoms are worse in the evening and is associated with cough and sore throat.

PMFSH – three reviewed

ROS – Ear, nose throat - positive sore throat


            Respiratory – Positive for cough


             Eight other systems reviewed and negative (need each documented in the note)


Exam – General – well developed well-nourished


ENT – clear nasal discharge noted, bilateral tympanic membranes without erythema, posterior               

pharynx with post nasal drip noted


Six other systems examined (all eight systems must be documented n the note


Diagnosis – 1.) body aches

                      2.) Cough

                      3.) sore throat

  • (HPI components)

  • (ROS systems)

  • (Systems examined ENT detailed)

As you can see from the above example or a 99204 the complexity of the patient is higher due to the systemic symptoms and therefore the level of risk is higher as well.  As you would expect with more complex patients CMS expects more exams to be performed and history to be taken.

The other option for billing for Evaluation and management codes is the unit of time.  For a 99204 the practitioner must spend at least 45 minutes face to face with the patient and half of the time spent counseling the patient on treatment, lab results, and planning.  All these components should be documented.