CPT Code 99202: Office Visit, New Patient, Low Complexity

What is an office visit, new patient, low complexity (CPT 99202)?

CPT code 99202 is a specific code used to report evaluation and management services for new patient visits in an outpatient setting. This code represents a low-complexity office or other outpatient visit with a new patient, characterized by straightforward medical decision making. A new patient is defined as one who has not received professional services from the physician, qualified healthcare professional, mental health providers, or another physician or qualified healthcare professional of the same specialty and subspecialty in the same group practice, within the past three years.

The CPT code 99202 is part of the new patient CPT code range (99202-99205) that healthcare providers use to bill for initial encounters. These codes differ significantly from those used for established patient visits (99211-99215), as new patient evaluations typically require more comprehensive assessment and documentation.

CPT code 99202 service includes three key components:

• Medical decision-making: The code represents straightforward medical decision-making or minimal-complexity cases. This level involves limited data review, a low risk of complications, and straightforward diagnoses.
• Time-based reporting: The average session length for a 99202 visit is typically 15-29 minutes of total time spent on the encounter date. This includes both face-to-face and non-face-to-face activities that the healthcare provider performs.
• History and examination: While no longer separately scored for code selection, a medically appropriate history and physical examination are still expected to be performed and documented based on clinical judgment and the nature of the presenting problem.

The implementation of this code reflects the healthcare industry's shift toward emphasizing medical decision-making involved in patient care rather than extensive documentation of history and physical examination elements that may not be relevant to the patient encounter.

CPT code 99202 documentation requirements

For a 99202 service, the medical record and proper documentation on the evaluation and management session should include:

• Medically appropriate history: Document relevant aspects of the patient's history that influenced clinical decision-making, including chief complaint, history of present illness, and pertinent past medical, family, and social history elements as clinically appropriate.
• Physical examination: Record relevant physical examination findings that informed the assessment and plan. The examination can be focused on the affected body area or organ system, but should be sufficient to establish or rule out conditions being considered.
• Medical decision making: Document evidence of straightforward decision making, which includes:
  • Limited number of diagnoses or management options
  • Minimal amount and/or complexity of data to be reviewed and analyzed
  • Minimal risk of complications, morbidity, or mortality
• Time: If billing is based on time, document the total time spent on the encounter date and briefly describe activities performed.

Thorough documentation practices not only support accurate coding but also help prevent claim denials. Common coding errors when using code 99202 include:

• Insufficient documentation of medical necessity for the visit
• Lack of specificity regarding the presenting problem
• Failing to document the time spent when using time as the controlling factor for code selection
• Not clearly demonstrating the straightforward nature of the medical decision-making level

CPT code 99202 billing guidelines

To appropriately bill CPT code 99202, providers must ensure:

New patient status

Confirm the patient meets the criteria for a new patient (no professional services received from the physician or qualified healthcare professional of the same specialty and subspecialty in the same group practice within the past three years).

Level of service

The service must meet requirements for:

• Straightforward medical decision making based on the number and complexity of problems addressed, diagnostic tests performed, the amount and/or complexity of data reviewed, and the risk of complications or morbidity/mortality
• OR 15-29 minutes of total time on the date of the encounter

Medical necessity

The service must be medically necessary and appropriate for the condition being treated or assessed.

Reimbursement considerations

Reimbursement rates for CPT code 99202 vary by payer, geographic location, and provider type.

Incorrect coding can also significantly impact a practice's cash flow and compliance status. Common billing errors with code 99202 include:

• Billing 99202 for established patients instead of using the appropriate established patient codes
• Upcoding to higher-level new patient codes (99203-99205) without sufficient documentation or medical necessity
• Failure to meet requirements for new patient status
• Not documenting sufficient time when using time as the basis for code selection

Other relevant codes

When considering the appropriate code for new patient visits, healthcare providers should be familiar with the full range of related CPT codes to ensure accurate coding:

• 99203: New patient office visit, low-level medical decision making or 30-44 minutes
• 99204: New patient office visit, moderate-level medical decision making or 45-59 minutes
• 99205: New patient office visit, high-level medical decision making or 60-74 minutes