The differences in CPT (Current Procedural Terminology) codes is one of the most important aspects of medical billing and coding for healthcare providers. Another myriad of offices may code outpatient visits with CPT code 99204 and CPT code 99205, two of the most utilized CPT codes for new patient office or other outpatient visits. While they might seem like similar codes, they are used for different reasons depending on patients’ conditions and care provided. In this article, we’ll outline the main differences between these two codes, when each should be used and billing tips to ensure accurate payment.
What Are CPT Codes 99204 and 99205?
CPT codes 99204 and 99205 are for office use or other outpatient visit involving a new patient, one who has not received professional services from the healthcare provider or another provider of the same specialty who belongs to the same group practice, within the past three years. These codes fall under the range of the CPT guidelines utilized by physicians, healthcare providers, and medical coders to determine the level of service delivered and how to classify their charge during a patient encounter.
CPT 99204:
This code is typically used when the physician spends approximately 45 minutes with the patient and provides a moderate level of complexity in medical decision-making (MDM).
CPT 99205:
This code is used for visits that require a higher level of complexity. It is assigned when the physician spends 60 minutes with the patient and the medical decision-making involved is more intensive and complex.
Key Differences Between CPT Code 99204 and 99205
Time Spent with the Patient
The two primary differences between CPT 99204 and CPT 99205 demonstrate the timeframe between the dialysis physician and the patient. For CPT 99204 (45 minutes of face to face) the physician takes face to face with the patient for minimum 45 min in case of CPT 99205 (60 minutes of face to face). This involves taking a medical history, performing an examination, and discussing a diagnosis and plan for treatment.
Level of Medical Decision Making (MDM)
Enter the whole complexity of medical decision making, which is what dictates the appropriateness of CPT 99204 or 99205. CPT 99204 requires moderate-level MDM and means moderate risk to the patient and some analysis of important medical information with treatment decisions. CPT 99205 requires high level of MDM, which in general means taking care of high risk problems or complex decision, usually after checking quite a bit of data or coordinating the care with others.
Clinical Complexity
The level of clinical complexity of the patient’s condition is what further differentiates the two codes. CPT 99204 is used for moderate complexity patients, where a reasonable number of diagnoses or treatment options are involved by the provider. On the other hand, CPT 99205 is only applicable to patients with high complexity conditions, with most cases to be less than 3 diagnoses or complex health issues requiring a more intensive evaluation and management.
When to Use 99204 or 99205?
While CPT 99204 and CPT 99205 share the same time component, they differ in terms of complexity of patient condition and the requisite level of care. Make sure to complete your physical exam, including a moderate amount of medical decision-making (CPT 99204, 45 minutes). This may include conditions where you need to deep dive, but not overly complex. In contrast, the CPT 99205 is reserved for patients who walk into the clinic high-complexity, taking a long time (60 min) and requiring wide decision-making. These might be situations in which the patient’s situation is complex, i.e. associated with considerable risks or multiple medical interventions.
Choosing between CPT code 99204 and CPT code 99205 can be crucial for proper billing and reimbursement. Before you jump into assigning the correct CPT code, you want to remember the complexity of the medical decision-making, time spent with the patient and the clinical details. Following these guidelines keeps healthcare providers from being stabbed less than a CPT billing nomenclature billing traps.
Common Billing Mistakes to Avoid
Billing errors associated with CPT 99204 and CPT 99205 can lead to underpayment, denied claims and audits that impact all facets of your practice’s revenue and operations. These errors commonly occur from misinterpretation of the CPT coding guidelines, lack of documentation, or incorrect use of the coding rules. Here are some of the billing errors healthcare providers need to be aware of:
1. Underestimating Time
One of the most common billing errors is to not accurately accounting for the amount of time spent with the patient. If the provider spends more or less time than the minimum required, they can bill for the wrong code if time is not tracked and documented correctly during a visit. For instance, if you have a physician who spends 50 minutes with a new patient but enters only 40 minutes, they might decide on CPT 99204 instead of 99205, and underutilize reimbursement.
Tip: Implement a system that accurately captures time spent with each patient, including time in the room speaking directly (face-to-face) and including time on deliberation of the diagnosis, treatment plan, and any other component of patient care. Keep detailed accounts, and ensure that the time is calculated on the basis of actual face-to-face interaction rather than just by the total time spent together in the office.
2. Misclassifying Complexity
One of the biggest billing mistakes is when providers select a higher-level code based only on the time they spent with the patient, and not the complexity of the case. CPT 99204 and CPT 99205 rely on medical decision-making (MDM) and degree of clinical complexity, which must be correctly evaluated prior to code selection.
Without establishing an accurate case complexity, for example, a physician who spent 60 minutes with a patient selecting CPT 99205 simply because they spent that amount of time with the patient, is one case example of a CPT code error. Conversely, a mid-level visit might be inappropriately billed as CPT 99204, even with a higher risk/decision-making process involved, whether that visit was level 3 or 4.
It’s essential that you assess not only the time spent with the patient but also the nature of the patient’s condition. The physician should consider:
- The severity of the problem
- The number of diagnoses and management issues
- The amount of data reviewed or the need for coordination with other specialists
- The risk of complications or morbidity involved with the patient’s condition
Misclassification can result in underpayment (if the visit is coded for a lower level of complexity than appropriate) or overpayment (if the visit is over-coded, which could lead to audits).
Tip: Always match the complexity of the case with the appropriate CPT code. Use medical decision-making as the guiding factor, not just the duration of the visit.
3. Incomplete Documentation
The second big error that leads to denied claims or audits is incomplete documentation. Particularly for new patient visits as CPT 99204 and CPT 99205, any type of CPT code you participate in being paid for must have detailed and accurate documentation supporting its rationale. Documentation must reflect the time with the patient, the complexity of the visit and medical decision making involved. Without these specifics, the chosen code can’t be verified, and the payer may decline payment.
Some common documentation oversights include:
- Lack of detail regarding the number of diagnoses or treatment options
- Missing information on the patient’s medical history and current condition.
- Failing to describe the level of risk or the need for additional tests or referrals.
Tip: Ensure all components of the visit are thoroughly documented. Include time stamps, a summary of diagnoses, any medical procedures performed, and the treatment plan discussed. The more complete and detailed the documentation, the less likely you are to face audit-related issues or underpayments.
Billing Tips for Accurate Reimbursement
To avoid errors and ensure that you are reimbursed appropriately for your services, it’s important to implement best practices for accurate CPT coding. Below are essential tips to optimize the reimbursement process:
1. Track Time Accurately
Automated time-logging tools or EMR Systems as Electronic Medical Records that capture the time spent during consult for each patient can be useful in this process. This way there is no ambiguity or confusion regarding time calculations and remember that only time spent in face-to-face contact with the patient is counted. Admin time or back office time spent on reviewing a patient history is not counted.
Tip: Ensure your practice has a way to document the precise face-to-face time with the patient. You could also enrich your dedicated time for any certain aspects of patient encounters as the complexity increases.
2. Thorough Documentation
Proper and full documentation is your protection during billing. This helps make sure that the care you provide matches up with the code you use to bill for it. Incomplete or insufficient documentation may lead to refusal by the payer to pay the claim and thus create an exhausted cycle with the healthcare provider submitting claims, only to receive delays in payment or denied claims.
Proper documentation should include:
- Detailed medical history (including any new or chronic conditions).
- Clinical findings, such as physical examination results and any diagnostic tests.
- Time documentation, clearly indicating the duration of the patient’s visit.
- A breakdown of treatment plans, including referrals or follow-up actions.
Tip: Make sure that your documentation is a priority for your practice so you can avoid issues on billings. Make sure that each and every component needed for the chosen CPT code is documented. Patient’s history, physical examination, diagnoses, risk factors and medical decision making should be documented completely. Full and correct documentation substantiates the selected code, supports reimbursement, and reduces audit risk.
3. Regular Staff Training
Billing guidelines and CPT codes are dynamic. Regular training sessions for clinical and administrative staff should be scheduled to keep the team compliant and limit errors. It helps them learn the new CPT guidelines, and the significance of accurate documentation and coding.
Staff should be trained in the following areas:
- Properly assessing complexity levels and time requirements for CPT codes.
- Identifying common billing mistakes and avoiding overcoding or undercoding.
- Understanding new coding regulations and any changes to existing guidelines.
- The importance of keeping patient records comprehensive and accurate.
Tip: Develop an ongoing training schedule and use real-life case examples to enhance staff understanding. When staff members are well-informed about billing procedures and CPT code guidelines, errors are less likely to occur.
4. Consult a Medical Billing Expert
If your practice deals with complex cases or high volumes of billing, it is well worth your time to speak with a medical billing consultant or even consider outsourcing to an experienced third-party billing company. They are familiar with CPT coding and can ensure that your practice is using the correct codes for every patient encounter.
Experts can assist with:
- Reviewing your practice’s coding procedures and identifying any gaps.
- Ensuring that new patient visits are properly coded with CPT 99204 or CPT 99205, based on the complexity of the case.
- Keeping your billing practices compliant with latest guidelines from both CPT and insurance providers.
- Performing claim audits to minimize errors and reduce the likelihood of rejected or delayed claims.
Tip: Consulting with a billing expert can streamline your coding process, reduce human errors, and increase the likelihood of correct and timely reimbursements.
Choosing the Right Code
Accurate CPT coding is really important to ensure your healthcare practice receive appropriate reimbursement for services delivered to patients. Deciding which code to use, whether it be CPT 99204 or CPT 99205, is based on the time taken for the visit, chief complaint complexity, and medical decision making level.
To avoid common billing mistakes and ensure timely reimbursement, focus on:
- Accurate time documentation,
- Correctly assessing the level of complexity for each case,
- Thoroughly documenting every aspect of the patient encounter, and
- Regularly training staff on coding and documentation best practices.
By following these best practices, healthcare providers can improve their billing accuracy, ensure proper compensation, and reduce the risk of audit or denial
FAQ - People Also Asks
This code is typically used when the physician spends approximately 45 minutes with the patient at a facility.
This code is used for visits that require a higher level of complexity. It is assigned when the physician spends 60 minutes with the patient
CPT 99205 is used when a provider spends approximately 60-74 minutes with the patient at a facility.
CPT code 93306 is used for a complete transthoracic echocardiogram, while CPT code 93308 is used for a limited transthoracic echocardiogram, which involves a more focused assessment and fewer components.