Does 99204 require prior authorization?

No, 99204 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 99204?

Medicare facility rate: $116.90. Non-facility rate: $177.36. Work RVU: 2.60.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

2.60

Facility

$116.90

Non-Facility

$177.36

All documentation requirements for the selected E&M code (history, exam, and medical decision-making per CPT guidelines or time-based criteria) must be met and retained in the medical record.
Documentation should specifically note the evaluation for sleep apnea and the clinical assessment of suitability for an oral appliance to support the medical necessity of the E&M claim.
Document cognitive-relevant history including factors potentially contributing to impairment (for example psychoactive medications, chronic pain, infection, depression, other brain diseases).
Document medical decision making that supports moderate-to-high complexity, including current and likely disease progression and the need for referrals for rehabilitative, social, legal, financial, or community services.

Oral surgeons (Provider Specialty 19) may bill Evaluation & Management (E&M) CPT codes 99202-99215 when evaluating patients with sleep apnea to determine suitability for placement of an oral appliance.
CPT 99483 is covered for Medicare beneficiaries who are cognitively impaired, including those diagnosed with Alzheimer’s disease, other dementias, or mild cognitive impairment.
CPT 99483 is covered when the clinician, based on observation or corroborating information from patient/family/caregiver/others, determines the patient is cognitively impaired even if no formal diagnosis yet exists, provided documentation confirms impairment and the narrative history that prompted suspicion.
Coverage applies when a comprehensive visit results in a written care plan and includes all required elements of the 99483 service (cognition-focused evaluation, moderate-to-high MDM, functional assessment, dementia staging, medication reconciliation, neuropsychiatric evaluation, safety evaluation, caregiver identification/needs, advance care planning, and written care plan shared at initial education/support).
Polysomnography (PSG) is covered when it records sleep staging with continuous monitoring for 6 or more hours and includes physician review, interpretation, and report.
PSG followed by a multiple sleep latency test (MSLT) is covered to diagnose narcolepsy, with MSLT performed after an overnight PSG.

A56006 — Billing and Coding: E&M Coding for Oral Surgeons

A59036 — Billing and Coding: Cognitive Assessment and Care Plan Service

L36593 — Polysomnography

L39266 — Cognitive Assessment and Care Plan Service

Ask Verity about documentation requirements, denial risks, or coverage in your state.