The 99202 CPT code is used for a new patient office or other outpatient E/M visit. It’s linear and is an elementary type of healthcare health decision. The service takes 15 to 29 minutes to select the code by time. Patient Status, medical decision making, Total time, documentation, and payer requirements are all important factors in accurate coding for 99202. This tutorial helps you understand the requirements of this code and some practical billing considerations.
What Is the 99202 CPT Code?
99202 CPT Code is an evaluation and management code for the patient’s initial visit to an office or other outpatient setting. It is a visit with simple medical decision making, determined by the level of MDM. The code can also be selected using total physician or qualified healthcare professional time. CPT time range for 99202 is 15 to 29 minutes. The service may include examination of a new concern, review of information, conduct of examination and the development of a management plan. Work documented should reflect the chosen level.
Who Qualifies as a New Patient?
New patient status is determined by the patient’s previous professional services with the physician or applicable physician group. Medicare generally considers a patient new when no professional service occurred within the previous three years.
CMS includes E/M services and other face-to-face professional services when determining this status. Diagnostic test interpretation alone does not necessarily change new patient status when no face-to-face service occurred. For example, a patient previously seen by the same specialty group four years ago may qualify as new. A patient seen by that same physician group within three years generally does not.
| Situation | New patient status |
|---|---|
| No professional service within three years | Generally new |
| Professional service within three years | Generally established |
| Diagnostic interpretation without face-to-face service | May remain new |
| Different specialty within same group | Depends on applicable rules |
Commercial payer definitions can differ, so coders should verify the payer’s current policy.
When Should You Report 99202 CPT Code?
Report 99202 CPT Code when a new patient receives an office or outpatient E/M service meeting the code’s requirements. The visit should involve straightforward MDM or qualifying total time. Typical encounters can involve relatively limited problems requiring evaluation and management. The clinician may review information, assess the patient’s condition, and establish an appropriate management approach. The code should reflect the actual level of service provided. It should not be selected solely because the patient is new to the practice.
How Is 99202 CPT Code Selected by MDM?
When using MDM, 99202 CPT Code corresponds to straightforward medical decision making. Office and outpatient E/M levels use three MDM elements for determining complexity.
These elements are:
- Problems addressed
- Data reviewed and analyzed
- Risk of patient management
The overall MDM level generally requires meeting or exceeding the required level in at least two of the three elements. Therefore, one complex element alone does not automatically establish the final E/M level. For 99202, the documentation should support straightforward complexity across the applicable MDM framework. Coders should evaluate what the clinician actually addressed rather than counting every item appearing in the medical record.
What Is the 99202 CPT Code Time Requirement?
If the E/M level is determined by time, 99202 is for 15 to 29 minutes of total physician or other qualified healthcare professional time on the date of the service. This time may be used for multiple activities done for the encounter. These include preparation for the visit, history taking or review, assessment of the patient, counseling, ordering services, documentation and communicating results if applicable.
Time doesn’t have to be spent on site all the time. CPT time based reporting takes into account qualifying activities on the day of the service. If the level of E/M service is determined by time, 99202 codes indicate 15 to 29 minutes of the total physician or other qualified health care professional time on the date of service.
This time may be used for multiple activities done for the encounter. Examples include preparation for the visit, obtaining/reviewing history, interpretation, counseling, ordering services, documenting, communicating findings as applicable.
The time need not be in-person only. Under CPT time based reporting, the date of service is when the qualifying activities occur.When MDM determines the level, documenting total time is not required solely to support the MDM-selected code.
99202 vs 99203: What Changes?
The primary difference is the level of medical decision making or qualifying total time supported by the encounter.
| Code | MDM level | Time when selected by time |
|---|---|---|
| 99202 | Straightforward | 15 to 29 minutes |
| 99203 | Low | 30 to 44 minutes |
| 99204 | Moderate | 45 to 59 minutes |
| 99205 | High | 60 to 74 minutes |
A longer encounter does not automatically require a higher code when MDM is used. Conversely, a higher MDM level can support a higher code when the documentation meets those requirements. AMA guidance confirms that CPT does not establish a preference between MDM and time. The method should reflect the documented circumstances of the encounter.
What Documentation Supports 99202 CPT Code?
The medical record should demonstrate the work performed during the new patient encounter. Documentation should also make the selected MDM or time-based level understandable.
Important documentation may include:
- Reason for the encounter
- Problems addressed
- Relevant history
- Appropriate examination or evaluation
- Data reviewed or analyzed
- Management decisions
- Treatment recommendations
- Orders or prescriptions
- Follow-up planning
- Total time when time determines code selection
Documentation requirements should reflect medical necessity and the actual services performed. Avoid relying on copied templates that contain information unrelated to the current encounter.
Can 99202 CPT Code Be Billed With Modifier 25?
If an E/M service, which is significant and separately identifiable, is rendered on the same date as another procedure/service, then modifier 25 will likely apply. Modifier 25 should be used to identify a separate E/M service from the other service, according to CMS.For instance, when a new patient presents a medical problem, the procedure may be performed and then a separate document is created for the other medical problem. The use of modifier 25 will depend on the documentation and situation.Modifier 25 can be used when a substantial and separate E/M service is provided on the same date as another procedure or service.
According to CMS, modifier 25 should be used to signify a separate E/M service, which is distinct from the other service. A modifier is not used just because another procedure was performed in the same visit. The record should document work in addition to that of the other service. For instance, a new patient might get a procedure, as well as an independently documented examination of another medical issue. The use of modifier 25 is dependent on the circumstances and documentation.
Can 99202 CPT Code Be Reported With Other Services?
A new patient E/M may be performed in conjunction with other services, if the coding requirements are met. But coders should check NCCI edits, bundling rules and payer-specific policies prior to submitting multiple services.When the coding requirements for a new patient E/M visit are met separately from any other service, the new patient E/M visit can be coded along with the other service. Coding, however, should be reviewed prior to reporting more than one service with NCCI edits, bundling rules and payer-specific policies.
NCCI edits are designed to identify code combinations that could lead to improper payments by CMS. Medically unlikely edits and procedure-to-procedure edits for Medicare Part B services are included in the program. If another service is reported on the same date, consider if the E/M can be separately identified. Modifier 25 can be used only if the criteria are satisfied.
Does G2211 Apply to 99202 CPT Code?
Medicare office or outpatient G2211 is an E/M complexity add-on code. When applicable, CMS allows G2211 with office and outpatient E/M codes 99202 CPT Code – 99205 when the applicable requirements are met. CMS will also permit some combinations with a modifier 25 and preventive service beginning on January 1, 2025, under certain conditions. These rules are not an indication that G2211 will automatically be covered for every 99202 visit.
G2211 has other eligibility and documentation criteria. It is important that coders check the latest Medicare guidance before reporting it with 99202 CPT Code.G2211 is an office or outpatient E/M complexity add-on code. If applicable, CMS allows G2211 to be used with office and outpatient E/M codes from 99202 – 99205, provided applicable requirements are met.
Additionally, CMS is making certain modifier 25 combinations under certain circumstances, effective January 1, 2025. The rules don’t imply that G2211 will always be applicable on every 99202 visit. There are other eligibility and documentation criteria for G2211. Medicare guidance should always be checked by coders prior to reporting it with 99202.
What Are the 2026 RVUs for 99202 CPT Code?
These RVUs are on the list for CPT 99202 in the CMS Physician Fee Schedule data for the current year (2026).
| 2026 RVU component | Value |
|---|---|
| Work RVU | 0.93 |
| Non-facility practice expense | 1.25 |
| Facility practice expense | 0.23 |
| Malpractice RVU | 0.07 |
| Total non-facility RVUs | 2.25 |
| Total facility RVUs | 1.23 |
The CMS release for Q4 2026 shows these component values. CMS uses work, practice expense and malpractice RVUs to determine the Physician Fee Schedule payment. These components are then adjusted for each Medicare locality using geographic practice cost indices.
What Is the 2026 Medicare Payment for 99202 CPT Code?
For 2026, the Medicare conversion factor is $33.4009, which is not a Qualified Payout Factor. CMS also set a conversion factor for those who are eligible for APM.
With national GPCIs set to 1.000, the 99202 number sets its calculation to roughly:
| Setting | Total RVUs | Approximate national amount |
|---|---|---|
| Office, non-facility | 2.25 | $75.15 |
| Facility | 1.23 | $41.08 |
These are national base numbers, prior to locality adjustments. Actual Medicare payment may vary due to geographic adjustments and other payment rules that apply.
Payment information and related RVUs for each locality are available in the CMS PFS Look-Up Tool.These are national baseline figures, before local adjustments. The Medicare payment may vary due to CMS geographic adjustments and other payment rules that may apply. Locality-specific payment information and related RVUs are available on the CMS PFS Look-Up Tool.
What Are Common 99202 CPT Code Billing Errors?
One of the most crucial mistakes to avoid is wrong new patient status. Before assigning the new patient code, the coders should review the previous professional services.One of the biggest mistakes to avoid is when the new patient status is incorrect. The new patient code should be considered carefully, given the experience the coders had with past professional services.
Other common problems include:
- Reporting 99202 CPT Code for an established patient
- Selecting 99202 CPT Code without supporting straightforward MDM
- Using time without documenting qualifying total time
- Reporting a higher code without sufficient support
- Automatically adding modifier 25
- Ignoring NCCI edits
- Reporting G2211 without meeting requirements
- Using outdated payer policies
- Selecting codes based only on visit length
These errors can affect claim payment and create unnecessary audit exposure. A consistent pre-submission review can help identify unsupported code selection.
How Does Place of Service Affect 99202 CPT Code?
Place of service affects the practice expense component used in Medicare payment calculations. Office services generally use the non-facility practice expense value, while facility services use the facility value. For 99202, the 2026 practice expense RVUs are 1.25 non-facility and 0.23 facility.
This difference contributes to different national payment amounts between office and facility settings. The final payment still depends on locality-specific geographic adjustments. Coders should therefore ensure that the reported place of service accurately represents where the service occurred.
99202 CPT Code Coding Example
A patient presents to a physician’s office for the first professional service with that physician group. The patient has a minor new complaint requiring evaluation and management. The clinician evaluates the problem, reviews relevant information, and develops a straightforward management plan. The documentation supports straightforward MDM.
The patient is a new patient and the MDM meets the applicable new patient definition, which results in the possible use of 99202. If the clinician chooses the code based on total time, then the qualifying time must be documented within the 15 – 29 minute range. The code selection method should be consistent with the codes that are documented in the encounter.
99202 CPT Code Claim Review Checklist
Before submitting a 99202 claim, review these points:
- Confirm the patient qualifies as new.
- Verify the applicable three-year history.
- Confirm the service occurred in an appropriate office setting.
- Determine whether MDM or time establishes the level.
- Verify straightforward MDM when using MDM.
- Confirm 15 to 29 minutes when using time.
- Review documentation for medical necessity.
- Check separately reported procedures or services.
- Apply modifier 25 only when supported.
- Verify G2211 requirements when applicable.
- Review NCCI and payer-specific edits.
- Confirm the place of service is accurate.
This checklist separates patient status, level selection, documentation, and claim editing. That approach helps reduce preventable 99202 billing errors.
Key Takeaways
The 99202 CPT code is used for new patient offices or other outpatient E/M services. It is simple medical decision making, where the level is defined by MDM.If time is utilized, the qualifying range is 15 to 29 minutes on the date of service. New patient status is defined by having received professional services from the same physician and/or specialty group within the previous 3 years.
In 2026, 99202 will have 0.93 work RVUs, 1.25 non-facility practice expense RVUs, 0.23 facility practice expense RVUs, and 0.07 malpractice RVUs. To ensure proper billing, patient classification, E/M level selection, documentation, and claim review should be completed.New patient offices/other outpatient E/M services are coded as 99202. When the level is determined by MDM, it is a simple medical decision making process.
If time is used, the qualifying range is from 15 to 29 minutes, on the date of the service. New patient status generally is based upon whether the patient has been served by the same physician or group specialty in the prior three years. To bill correctly, patient classification, E/M level selection, documentation, and claim review must be performed accurately and is a payer-specific process.
