Document requirement for CPT CODES 99204 and 99205

Prepayment of evaluation and management codes 99204 and 99205

Data analysis was conducted recently due to the high comprehensive error rate testing (CERT) error rate for evaluation and management service pertaining to Current Procedural Terminology (CPT®) codes 99204 (Office/outpatient visit new) and 99205 (Office/outpatient visit new). CERT reviews indicated the errors were based on insufficient documentation and services coded incorrectly.

Documentation requirements

The American Medical Association (AMA) CPT® manual defines code 99204 as follows:
Office or other outpatient visit for the evaluation and management (E/M) of a new patient, which requires these three key components:
• A comprehensive history
• A comprehensive examination
• Medical decision making of moderate complexity.

Usually the presenting problem(s) are of moderate to high severity. Typically, 45 minutes are spent face-to-face with the patient and/or family.
The American Medical Association (AMA) CPT® manual defines code 99205 as follows:

Office or other outpatient visit for the evaluation and management (E/M) of a new patient, which requires three key components:

• A comprehensive history
• A comprehensive examination
• Medical decision making of high complexity.

Usually the presenting problem(s) are of moderate to high severity. Typically, 60 minutes are spent face-to-face with the patient and/or family.
Furthermore, claims submitted with E/M code 99204 and 99205 must be supported by documentation indicating the medical necessity for this level of service.