Healthcare providers use a standardized language to bill for the services they provide, known as Current Procedural Terminology (CPT) codes. CPT codes are five-digit numerical codes that describe medical, surgical, and diagnostic services offered to patients. They ensure that all parties—physicians, hospitals, and insurance companies—are referencing the exact same service.
Office visits and other clinical encounters fall under a specific subset of this system called Evaluation and Management (E/M) services. E/M codes focus on the cognitive work performed by the healthcare professional, such as the assessment and planning involved in a patient’s care. These codes are fundamental to how providers are reimbursed for their time and expertise in managing patient health.
Understanding the New Patient Designation
Selecting the correct CPT code requires determining if the individual is classified as a “new patient” or an “established patient.” A patient is designated as new if they have not received any professional services from the physician or another physician of the same specialty within the same group practice within the previous three years.
This definition focuses on the specialty and group affiliation of the provider. For example, if a patient saw a cardiologist in a multispecialty clinic three years and one day ago, and now sees a different cardiologist in the same clinic, they are considered a new patient. If a patient saw any physician of the same specialty within that group just two years ago, they are considered an established patient for all providers of that specialty within the group.
The classification matters because new patient visits generally require more work to collect a complete history and establish a care plan. This additional complexity is reflected in the distinct codes used for new patients, which are separate from the established patient codes (the 99212–99215 series). Separate code ranges also often reflect differences in reimbursement rates.
The Specific CPT Codes for Initial Office Visits
The CPT codes used for new patient office or outpatient Evaluation and Management services are found in the range 99202 through 99205. These four codes represent increasing levels of complexity and work involved in the encounter.
CPT code 99202 is used for a straightforward visit, often involving a single, minor problem and minimal risk. Code 99203 reports a low level of medical decision making, appropriate for a patient with a stable chronic illness or a slightly more complex acute issue. Moving up, CPT code 99204 is used when the visit involves a moderate level of medical decision making, such as managing an uncontrolled chronic condition.
The highest level of service, CPT code 99205, is reserved for encounters involving the most complex medical decision making, such as a severe exacerbation of a chronic condition or a life-threatening illness. Although a medically appropriate history and examination are always necessary, the selection between these four codes is primarily based on the complexity of the service provided.
Criteria for Selecting the Appropriate Code Level
Selecting the correct level from the 99202–99205 series is based on one of two criteria: the complexity of Medical Decision Making (MDM) or the total time spent on the date of the encounter. Providers may choose either factor to justify the code level, but they must ensure their documentation supports the chosen factor.
Medical Decision Making (MDM)
MDM is a measure of the complexity involved in establishing a diagnosis and selecting a management option for the patient. It is categorized into four levels corresponding to the codes: straightforward (99202), low (99203), moderate (99204), and high (99205). The determination of the MDM level relies on an assessment of three distinct elements during the patient encounter.
To qualify for a specific MDM level, the provider must meet or exceed the requirements for at least two of these three elements:
- The number and complexity of the problems addressed during the visit. This considers whether the patient presents with a single minor issue, multiple stable chronic conditions, or a new problem with an uncertain prognosis.
- The amount and complexity of data the provider must review and analyze. This includes reviewing laboratory results, imaging studies, external medical records, or obtaining a history from an independent source.
- The risk of complications, morbidity, or mortality associated with the patient’s condition and the management options selected. Examples range from minimal risk, such as a routine blood draw, to high risk, which could involve decisions regarding major surgery or intensive drug therapy.
Total Time
The second method for determining the code level is the total time spent by the physician or other qualified healthcare professional on the date of the encounter. This time includes all activities related to the patient’s care, not just the face-to-face interaction.
Each new patient code is associated with a specific time range that must be met or exceeded to justify the level. For instance, a 99202 requires a total time of 15 to 29 minutes, while the highest level, 99205, requires 60 to 74 minutes of total time spent.