November 16, 2017
When I see an adult new patient with a chief complaint of dizziness, I can automatically code a level 4, 99204, right?
Oh, only if E/M coding were that easy! Don’t forget, for 99204 you must have medical necessity for and perform a comprehensive History and a comprehensive Exam (8 organ systems for the 1995 guidelines, meet the assessment “bullets” which include a laryngeal mirror exam for the 1997 guidelines). Lastly, the medical decision making must be of moderate complexity. Meeting all 3 of these requirements is mandatory for 99204 and may not be easily met when the chief complaint is dizziness. There is potential for the counseling time requirement of 45 minutes of face-to-face time, with greater than 50% of it being spent counseling, to be met to support 99204. Be sure to appropriately document this and your specific discussion points if choosing the code based solely on time counseling on the dizziness.
*This response is based on the best information available as of 11/16/17.