Current Procedural Terminology (CPT) codes serve as the standardized language used for medical billing, providing a uniform method to describe the services a healthcare provider delivers to a patient. These five-digit codes are published and maintained by the American Medical Association (AMA) and are necessary for providers to communicate with payers, such as insurance companies and government programs, to ensure accurate reimbursement. Significant revisions to the codes for office and outpatient visits, known as Evaluation and Management (E/M) services, took effect in 2021. The updated guidelines moved away from the previous focus on documenting extensive patient history and physical examination elements. Instead, the current system bases code selection primarily on the complexity of Medical Decision Making (MDM) or the total time spent with the patient on the date of the encounter.
Determining New Patient Status
The distinction between a new patient and an established patient is the first step in selecting the correct CPT code for an office visit. According to the CPT guidelines, a patient is classified as “new” if they have not received any professional services from the physician or another qualified healthcare professional within the same group practice within the previous three years. This is often referred to as the “three-year rule,” and it applies to professional services rendered by any provider of the exact same specialty and subspecialty within that group.
An interpretation of a diagnostic test, such as reading an X-ray or EKG, in the absence of a face-to-face E/M service, does not count as a professional service that changes a patient’s status from new to established. Therefore, if a patient’s last interaction with the practice three years ago was only a blood test reviewed by a provider they did not meet in person, they would still be considered a new patient for the subsequent office visit. The determination is specific to the specialty and subspecialty; a patient who sees a cardiologist in a large multi-specialty group may be considered a new patient to a dermatologist in the same group if the specialties are distinct.
The Current CPT Codes for Office Visits
The CPT codes specifically designated for new patient office or outpatient Evaluation and Management visits are in the range of 99202 through 99205. These codes represent four distinct levels of service complexity, ranging from the most straightforward encounter to the most highly complex. The lowest level code, 99201, which was previously used for minimal problem-focused visits, was deleted as part of the 2021 revisions to the E/M guidelines.
CPT code 99202 is now the entry point for a new patient visit, representing a service that involves a straightforward level of Medical Decision Making. CPT code 99203 is used for encounters with a low level of complexity, often involving a stable chronic illness or a new, simple acute illness. Progressing upward, 99204 describes a service requiring a moderate level of complexity, which is commonly used for patients with an exacerbation of a chronic condition or a new problem needing significant diagnostic workup.
The highest level of service is designated by CPT code 99205, which is reserved for the most complex new patient encounters. This level signifies a high level of Medical Decision Making, often involving severe acute or life-threatening problems. The complexity level directly correlates with the amount of work performed by the provider and the reimbursement received.
Selecting the Appropriate Code Level
The selection of the appropriate CPT code level (99202–99205) for a new patient visit is determined by the provider using one of two primary methods: the level of Medical Decision Making (MDM) or the total time spent on the date of the encounter. The provider is free to choose the method that best reflects the nature of the visit and results in the highest supported code level.
Medical Decision Making (MDM)
Medical Decision Making is categorized into four levels: straightforward, low, moderate, and high, which correspond directly to the four available new patient codes. To qualify for a specific MDM level, the documentation must meet or exceed the requirements in at least two of three defined elements.
The three elements of MDM are:
- The number and complexity of problems addressed during the encounter.
- The amount and/or complexity of data that must be reviewed and analyzed.
- The risk of complications and/or morbidity or mortality of patient management.
For instance, qualifying for a moderate MDM level, which corresponds to CPT code 99204, requires meeting the criteria for moderate complexity in two of the three elements. This might involve addressing a chronic illness with exacerbation, reviewing three unique sources of data such as old records and imaging results, and making a decision with a moderate risk of complication, such as starting a new prescription medication. Documenting the work performed within each of these three elements is necessary to justify the final MDM level selected.
Total Time
Alternatively, the provider may choose to bill the visit based on the total time spent on the date of the encounter. This time includes all activities performed by the physician or other qualified healthcare professional, both face-to-face with the patient and non-face-to-face. Reviewing tests and records, counseling the patient, documenting the encounter in the medical record, and communicating with other healthcare professionals all count toward the total time. Time spent by clinical staff, such as a nurse or medical assistant, is not included in this total calculation.
Each new patient CPT code has a corresponding time range that must be met to justify the level of service:
- CPT code 99202 requires a total time of 15 to 29 minutes.
- CPT code 99203 is assigned for 30 to 44 minutes.
- CPT code 99204 requires a total time of 45 to 59 minutes.
- CPT code 99205 is used when the total time spent by the provider is 60 to 74 minutes.
How New and Established Patient Codes Differ
The codes for established patient office visits follow a similar structure but are distinct from the new patient codes (9920x series). Established patient codes fall within the 99211 through 99215 range. The core difference in documentation requirements stems from the established provider-patient relationship, which typically means a detailed history is already available.
The most significant distinction is the existence of CPT code 99211, which has no requirement for MDM or time and is used for minimal service encounters that may not require the presence of the physician. This code is often used for services like a simple blood pressure check performed by a nurse under the physician’s supervision. The remaining established patient codes (99212–99215) are selected based on MDM or time, just like the new patient codes, but the time thresholds are lower for equivalent complexity levels. For example, the highest level established patient code, 99215, requires 40 to 54 minutes of total time, whereas the new patient equivalent, 99205, requires 60 to 74 minutes.