What Does CPT Code 99202 Mean?

CPT code 99202 describes a level 2 new patient office or other outpatient visit that involves a straightforward level of medical decision making (MDM). This code is the entry-level new patient E and M code (99202-99205), representing the lowest-complexity new patient visit. It is typically used when a new patient presents with one self-limited or minor problem that requires a medically appropriate history and examination with straightforward decision-making.

Key Code Attributes:

• Billable Status: Fully billable for new patient encounters with straightforward MDM
• Primary Setting: Office or other outpatient setting
• Provider Type: MD/DO, NP, PA, CNM, CNS (any licensed provider)
• Visit Type: New patient (not seen by same provider or same specialty in the same group within the past 3 years)
• MDM Level: Straightforward
• Time Threshold: 15-29 minutes total time on date of service (if time-based)
• Medicare Payment: ~$90-115 (non-facility, 2026 estimated)
• Audit Risk: Low — straightforward MDM is well-defined and less commonly miscoded

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What Services and Procedures Does CPT Code 99202 Cover?

CPT 99202 encompasses new patient encounters where the presenting problem is of minimal to low severity and requires straightforward MDM. This code is commonly used when a patient new to the practice presents for a focused evaluation of a single minor issue.

Covered Clinical Presentations (Examples):

• New patient presenting with seasonal allergies for evaluation and prescription antihistamine
• New patient requesting refill of birth control (no complications, previously on same regimen from another provider)
• Mild contact dermatitis requiring topical corticosteroid prescription
• Insect bite with localized reaction requiring antihistamine or topical treatment
• Uncomplicated urinary tract infection symptoms in an otherwise healthy patient
• Mild conjunctivitis requiring antibiotic eye drops
• New patient requesting weight loss counseling and basic dietary guidance
• Suture removal from a recent procedure performed by a different provider

What Does CPT 99202 Specifically Exclude?

• Low-complexity new patient visits — Use 99203 for low MDM (2+ self-limited problems, 1 stable chronic illness, or 1 acute illness with systemic symptoms)
• Moderate-complexity new patient visits — Use 99204 for moderate MDM (chronic illness exacerbation, undiagnosed new problem with uncertain prognosis)
• Highest-level new patient visits — Use 99205 for high MDM (severe exacerbation, threat to life/function)
• Established patient visits — Use 99211-99215 if patient has been seen within the past 3 years by the same specialty in the same group
• Preventive medicine visits — Use 99381-99397 (routine physical, well-woman, well-child)
• Telephone or audio-only visits — Use 99421-99423 or 99441-99443
• Emergency department visits — Use 99281-99285
• Inpatient or observation initial care — Use 99221-99223

Important New Patient Rule: If the patient was seen by a provider of the same specialty in the same group practice within the past 3 years, they are considered established. Different specialty within the same group = new patient. Same specialty in a different group = new patient.

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When Is CPT Code 99202 the Right Code to Use?

Correct code selection for new patient visits depends on either: (1) the level of medical decision making (MDM) as defined by the 2021 AMA E and M guidelines, or (2) the total time spent on the encounter date if counseling and/or coordination of care dominates the visit.

Step-by-Step Code Selection Criteria

1. Confirm the patient is new:

   • Not seen by any provider of the same specialty in the same group practice within the past 3 years
   • Different specialty within same group = new patient
   • Same specialty in different group = new patient
   • If seen within 3 years by same specialty/group = established patient (use 99211-99215)

2. Assess MDM level — Straightforward requires at least ONE of the following:

   • One self-limited or minor problem
   • Minimal or no data review
   • Minimal risk of complications or morbidity

3. Data reviewed — Minimal or none:

   • No external records need review
   • Test ordering may be present but is not required
   • Independent interpretation of a test not typically present

4. Risk level — Minimal risk:

   • No prescription drug management required
   • Over-the-counter medications suggested
   • Minor procedures with minimal risk
   • Lifestyle or dietary counseling

5. If using time: verify total time on date of service

   • 99202: 15-29 minutes total time
   • Must document >50% of total time was spent on counseling and/or coordination of care
   • Total time includes face-to-face and non-face-to-face work on the date of service (preparation, chart review, documentation, care coordination)

How Does CPT 99202 Differ From the Most Commonly Confused Codes?

Comparison: CPT 99202 vs. 99203 vs. 99204

Aspect	CPT 99202	CPT 99203	CPT 99204
MDM Level	Straightforward	Low	Moderate
Typical Time	15-29 minutes	30-44 minutes	45-59 minutes
Problems	1 self-limited or minor problem	2+ self-limited/minor, OR 1 stable chronic, OR 1 acute with systemic symptoms	1+ chronic with exacerbation, OR 1 undiagnosed new problem with uncertain prognosis
Data Reviewed	Minimal or none	Minimal — lab review or test ordering	Moderate — external notes review, OR test interpretation, OR test ordering
Risk Level	Minimal	Low	Moderate
Common Example	New patient for seasonal allergy evaluation	New patient HTN + DM initial workup	New patient diabetes with neuropathy workup
Medicare Payment	~$90-115	~$130-160	~$170-205
Audit Risk	Low	Moderate	Moderate-High

Comparison: CPT 99202 vs. 99212 (New vs. Established Straightforward Equivalent)

Aspect	CPT 99202 (New)	CPT 99212 (Established)
Patient Type	New (not seen in 3 years)	Established (seen within 3 years)
MDM Level	Straightforward	Straightforward
Time Threshold	15-29 minutes	10-19 minutes
Typical Content	Medically appropriate history and exam	Problem-focused history and exam
Medicare Payment	~$90-115	~$55-80
Key Difference	New patient — no prior relationship; inherently more work to establish history	Established patient — prior history available; more focused

Critical Note: Both 99202 and 99212 require straightforward MDM, but the new patient code (99202) expects more comprehensive work due to the absence of prior records and relationship. The time threshold is higher (15-29 min vs. 10-19 min) and reimbursement is approximately 50% greater.

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What Documentation Is Required to Support CPT 99202?

Documentation for 99202 must support straightforward MDM under the 2021 AMA E and M guidelines. New patient visits typically include a more comprehensive history and examination, but MDM remains the primary code level determinant.

What Must the Provider Document for Straightforward MDM (99202)?

MDM Element	Straightforward (99202) Requirement	Documentation Examples
Problems Addressed	1 self-limited or minor problem	”Seasonal allergic rhinitis — itchy eyes, sneezing, clear rhinorrhea × 2 weeks — prescribed cetirizine daily and fluticasone nasal spray”; “Uncomplicated UTI — dysuria, frequency — prescribed nitrofurantoin”
Data Reviewed & Analyzed	Minimal or none; may include ordering of a single test	”Reviewed pharmacy records — confirmed no recent antibiotic use”; “Ordered urinalysis — pending results”
Risk of Complications	Minimal risk: OTC medications, dietary counseling, no prescription drugs (unless low-risk)	“Recommended OTC antihistamine and saline nasal spray”; “Counseled on UTI prevention and hydration”

Important: For new patients with straightforward MDM, the history and exam should be medically appropriate but do NOT need to be comprehensive. A focused history and exam addressing the single presenting problem is sufficient if supported by the clinical presentation.

How Do the 2021 AMA E and M Guidelines Apply to This Code?

Key 2021 Changes Affecting 99202:

• No history/exam level requirements — Prior guidelines required comprehensive history and exam for new patients. Now, history and exam are “medically appropriate.”
• MDM or Time is the code level determinant — Straightforward MDM is the lowest level; if time is used, 15-29 minutes total time
• Time definition expanded — 15-29 minutes total time includes all work on the date of service
• New patient definition unchanged — The 3-year rule for new vs. established patient status remains the same

Facility vs. Non-Facility Documentation Standards

Non-Facility (Office/Clinic): The provider’s documentation must independently justify 99202. The entire reimbursement goes to the provider.

Facility (Outpatient Hospital): The provider bills the professional component. Documentation standards are identical. The facility bills a separate facility fee.

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How Does CPT Code 99202 Affect Medical Billing and Reimbursement?

RVU Breakdown for CPT 99202

RVU Component	2025 Value	2026 Value (Estimated)	Impact on Billing
Work RVU	0.93	0.93	Reflects provider effort for straightforward new patient evaluation
Practice Expense RVU (Non-Facility)	1.12	1.12	Office overhead for new patient intake
Practice Expense RVU (Facility)	0.37	0.37	Reduced in facility settings
Malpractice RVU	0.06	0.06	Professional liability
Total RVU (Non-Facility)	2.11	2.11	Office/clinic billing
Total RVU (Facility)	1.36	1.36	Hospital outpatient billing

Medicare Reimbursement Calculation (Non-Facility, 2026):

• Total RVU: 2.11 × $32.98 (CF) = **$69.59**
• Geographic adjustment (GPCI): Multiply by locality factor
• Final estimated payment: ~$90-115 (varies by region)

With G2211 Add-On Code:

• G2211 adds approximately 0.33 RVU
• Additional payment: ~$10-15
• Combined total: ~$100-130

Commercial Payer Reimbursement Benchmarks (2026):

• Blue Cross Blue Shield: $120-160 mean rate
• Cigna Health: $100-135 average
• Aetna: $95-125 average
• UnitedHealth: $85-115

What Modifiers Are Commonly Used With CPT 99202?

Modifier	Description	When to Apply	Billing Impact
-25	Significant, separately identifiable E and M on same day as procedure	E and M + procedure same day for new patient	Allows billing both codes
-24	Unrelated E and M during post-op period	Rare for new patients	Prevents bundling
-95	Synchronous telemedicine	Audio-video visit	Required for Medicare telehealth
G2211	Visit complexity add-on	Complexity beyond typical	Additional ~$10-15

Are There Any Prior Authorization or LCD Requirements?

Medicare Coverage: Nationally covered. No specific LCD for 99202. Coverage follows general E and M medical necessity rules.

Key Denial Reasons:

• “New patient status not verified” — Verify 3-year rule
• “Medical necessity not supported” — Document reason for new patient visit
• “Duplicate visit” — Only one new patient E and M per day

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What CPT or HCPCS Codes Are Commonly Billed Alongside CPT 99202?

Associated Code	Description	Billing Guidance
-25 modifier procedures	Skin biopsy, joint injection, I and D	Append -25 to 99202
CPT 93000	EKG	Bill separately; no modifier
CPT 81000-81003	Urinalysis	Bill separately
CPT G2211	Complex visit add-on	Append to 99202

NCCI Edits: 99202 does NOT bundle with most procedures when -25 is appended. G2211 is an add-on code with no conflict.

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What Coding Errors Should You Avoid With CPT 99202?

Top Coding Errors Ranked by Frequency:

1. Using 99202 for an established patient — Most common error. Verify new patient status: not seen within 3 years by same specialty in the same group.
2. Upcoding 99202 to 99203 — If only one self-limited problem with straightforward MDM, 99202 is appropriate. Do not upcode to 99203 simply because the patient is new.
3. Downcoding to 99212 — Using the established patient equivalent for a new patient. New patient = 99202 (not 99212).
4. New patient rule applied incorrectly — Different specialty in same group = new. Same specialty in different group = new.
5. Missing -25 modifier when procedure performed — E and M portion denied if a procedure is performed on the same day without modifier -25.
6. Billing 99202 when preventive visit is more appropriate — If the visit is solely preventive (no problem-focused component), use 99381-99397.

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How Does CPT 99202 Relate to Other CPT Codes?

Related Code	Relationship	Key Distinction
99203	Higher level	Low MDM — 2+ self-limited problems or 1 stable chronic illness
99204	Higher level	Moderate MDM — chronic exacerbation or undiagnosed problem
99205	Highest level	High MDM — threat to life/function
99212	Established equivalent	Straightforward MDM for established patients
99381-99397	Preventive	Not problem-focused; can be billed same day with -25

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Real-World Coding Scenario — How CPT 99202 Is Applied in Practice

Patient Scenario: A 22-year-old female new to the practice presents with a 3-day history of itchy, watery eyes and sneezing during spring season. She has no significant past medical history, takes no medications, and has never been evaluated for allergies. Physical exam shows mildly injected conjunctiva, clear rhinorrhea, and no sinus tenderness. Provider discusses seasonal allergic rhinitis, recommends OTC cetirizine and fluticasone nasal spray, educates on trigger avoidance, and schedules follow-up if symptoms persist. Total time: 18 minutes, 8 minutes counseling on allergy management.

Correct Code: CPT 99202

• Straightforward MDM: One self-limited or minor problem (seasonal allergic rhinitis)
• Data: No external records reviewed, no tests ordered
• Risk: OTC medication recommendation only (minimal risk)
• Time-based also supports 99202 (18 min within 15-29 min range)

Common Mistake: Billing 99203 — The presenting problem is a single self-limited condition (seasonal allergies) with straightforward MDM. Despite the patient being new, the MDM level is straightforward, not low. Upcoding to 99203 for a straightforward MDM encounter would be a compliance risk.

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Frequently Asked Questions About CPT Code 99202

Is CPT Code 99202 Still Valid for Use in 2026?

CPT code 99202 remains a valid, active, billable code for fiscal year 2026 with no changes to its descriptor, RVU values, or coding guidelines. The code has been stable under the 2021 E and M guidelines and is not scheduled for retirement. Verify annually against AMA CPT updates and CMS MPFS.

What Is the Difference Between CPT 99202 and 99212?

CPT 99202 is for new patients (not seen within 3 years) with straightforward MDM and requires 15-29 minutes total time, while 99212 is for established patients with straightforward MDM and requires 10-19 minutes total time. The MDM level is the same (straightforward), but new patient visits inherently require more work to establish the patient’s history. Reimbursement for 99202 is approximately 50% higher than 99212 (~$90-115 vs. ~$55-80).

How Do I Verify New Patient Status for 99202?

A patient is considered new if they have not received any professional services from a physician or other qualified healthcare professional of the same specialty in the same group practice within the past 3 years. Different specialty within same group = new. Same specialty in different group = new. If the patient was seen by a provider but the specialty is different, they are still a new patient for your specialty.

Can I Bill CPT 99202 and a Preventive Visit on the Same Day?

Yes, you can bill both 99202 and a preventive medicine code (99381-99397) on the same day if a significant, separately identifiable problem-focused E and M service is performed. Append modifier -25 to 99202, and document the problem-focused service separately from the preventive components.

What Is the Medicare Reimbursement Rate for CPT 99202 in 2026?

Medicare reimbursement for 99202 in 2026 is approximately $90-115 depending on geographic location. The base RVU is 2.11 (non-facility) multiplied by the conversion factor. Commercial payer rates range from $85-160.

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Key Takeaways for Billing and Coding CPT 99202

• Code Purpose: Level 2 new patient office visit with straightforward MDM
• Straightforward MDM: 1 self-limited or minor problem, minimal risk, minimal data
• New Patient Rule: Not seen in 3 years by same specialty in the same group
• Time-Based: 15-29 minutes total time with >50% counseling/coordination
• Reimbursement: Medicare ~$90-115; Commercial ~$85-160
• Common Error: Upcoding to 99203 when MDM is straightforward, or confusing with 99212

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Additional Resources and References

• CMS Physician Fee Schedule (PFS): CMS MPFS lookup tool
• CMS Medicare Claims Processing Manual (Chapter 12 - E and M): Pub. 100-04
• AMA CPT Code Set, Professional Edition (2026): American Medical Association
• CMS National Correct Coding Initiative (NCCI): NCCI Edits Database
• AHA Coding Clinic: AHA Coding Clinic