Evaluation and Management Coding for New Patients with Two Acute Problems
A new patient with two acute problems should be coded as 99204 if the visit involves a comprehensive history, comprehensive examination, and moderate complexity medical decision making.
Understanding 99204 Coding Requirements
According to the American Academy of Pediatrics guidelines, a 99204 code is appropriate for new patient evaluations that are detailed and moderately complex or take at least 45 minutes (with more than half spent counseling) 1. The key components that justify a 99204 code include:
- History: Comprehensive history
- Examination: Comprehensive examination
- Medical Decision Making: Moderate complexity
- Time: Typically 45 minutes face-to-face
Medical Decision Making Complexity
When evaluating two acute problems, the medical decision making often reaches moderate complexity due to:
- Multiple diagnoses or management options
- Moderate amount of data to review
- Moderate risk of complications, morbidity, or mortality
Key Factors to Consider When Coding 99204
Documentation Requirements
- Must document all elements of a comprehensive history
- Must document a comprehensive examination
- Must document moderate complexity decision making
Common Pitfalls to Avoid
- Insufficient documentation of the extent of history or examination
- Failure to document the complexity of medical decision making
- Not documenting time spent when using time as the controlling factor
When to Consider Other Codes
Consider 99203 if:
- Only a detailed history and examination were performed
- Medical decision making is of low complexity
- Visit typically takes 30 minutes
Consider 99205 if:
- Medical decision making is highly complex
- Visit typically takes 60 minutes
- The problems pose a significant threat to life or bodily function
Clinical Examples Supporting 99204 for Two Acute Problems
Two acute problems often require moderate complexity decision making because:
- Multiple management options must be considered
- Diagnostic testing may be needed for both problems
- Treatment plans must address both conditions
- Risk assessment must consider potential interactions between conditions
Documentation Tips
To support a 99204 code, ensure documentation includes:
- Chief complaints for both acute problems
- Comprehensive review of systems
- Comprehensive past medical, family, and social history
- Comprehensive examination of multiple body areas/organ systems
- Clear assessment of each problem
- Treatment plan addressing each problem
- Time spent (if using time-based coding)
Remember that the complexity of medical decision making is a key factor in determining the appropriate E/M code. Two acute problems typically involve moderate complexity decision making, supporting the use of 99204 for new patients.