The 99212 CPT code is for an established patient office or other outpatient evaluation management visit. It is applicable if the provider assesses and addresses a relatively simple issue and the encounter is limited to this level of service.
The selection of 99212 CPT code is not based on a specific history or examination template as with older E/M coding rules. Usually, the level is determined by medical decision making (MDM) or by the total time on the date of the encounter for office and outpatient evaluation and management (E/M) services.
Knowing these requirements aids in the ability to choose 99212 appropriately for providers and billing staff. It also helps eliminate patient status, time documentation, medical necessity, modifiers and over-coding errors.
Quick Answer
99212 CPT code describes an established patient office or other outpatient evaluation and management (E/M) visit. The service is simple medical decision making and is being used for code selection. When selecting the code by time, the provider must document 10 to 19 minutes of total time on the date of the encounter.
According to CPT patient status rules, the patient must be established with the provider or another qualified healthcare professional (HCP), of the same specialty, within the same group.
99212 CPT Code at a Glance
| Coding Element | 99212 Details |
|---|---|
| CPT code | 99212 |
| Service type | Office or other outpatient E/M |
| Patient status | Established |
| MDM level | Straightforward |
| Time when selected by time | 10 to 19 minutes |
| Primary setting | Office or other outpatient |
| Typical service | Follow-up or evaluation of a minor problem |
| History requirement | Medically appropriate |
| Examination requirement | Medically appropriate |
| Time-based selection | Yes |
| MDM-based selection | Yes |
| Common comparison | 99211 and 99213 |
| Modifier 25 | May apply when requirements are met |
| 2026 work RVU | 0.70 |
| 2026 non-facility PE RVU | 1.02 |
| 2026 facility PE RVU | 0.17 |
| 2026 malpractice RVU | 0.06 |
| 2026 total non-facility RVUs | 1.78 |
| 2026 total facility RVUs | 0.93 |
What Is the 99212 CPT Code?
The 99212 CPT Code description is an E/M office or other outpatient services provided by an established provider. One of the five codes for established patient office visits (99211-99215). The code is widely applicable for encounters where simple, basic medical decision making is required. Or the provider can choose to use 99212 CPT code because the documented time is within the range.
The service may include evaluation of a new complaint, follow-up on an ongoing complaint, medication related management, or other medically necessary problems that were discussed during the service. The actual service to be provided must be supportive of the selected level.
Who Can Be Billed Under 99212?
99212 CPT code is only for an established patient. In general, a patient is considered an established patient if he or she has seen the physician or another physician or qualified health care professional of the same specialty and has been in the same group practice in the last three years for E/M coding purposes.
Patient status needs to be known before coding. The patient is said to be established if he/she has been provided with a professional service within the past three years. This service should be provided by either the same physician or another healthcare professional within the same group practice. Both the physicians should belong to the same specialty and subspecialty as per the CPT guidelines.
This distinction matters because new patient office visits use codes 99202 through 99205. Established patient services use 99211 through 99215.
When Should You Use 99212 CPT code?
Use 99212 when the documented encounter supports this level of established patient E/M service.
Common situations can include:
- Follow-up of a stable, minor condition
- Evaluation of a self-limited problem
- Management involving straightforward decision making
- Review of a condition requiring limited management
- Follow-up after a previous treatment
- Evaluation of a minor complaint
- A brief established patient visit requiring medically necessary E/M work
The diagnosis itself does not automatically determine whether 99212 is appropriate. The provider’s documented work, medical necessity, MDM, or total time must support the selected level.
99212 Medical Decision Making Requirements
When MDM determines the level, 99212 CPT code corresponds to straightforward medical decision making.
Medical decision making includes three elements:
- Number and complexity of problems addressed
- Amount and complexity of data reviewed and analyzed
- Risk of complications and/or morbidity or mortality of patient management
The overall MDM level is determined using the applicable CPT framework. The documentation should demonstrate the work that supports the selected level. For 99212 CPT code, the encounter generally involves a straightforward clinical decision-making process. The provider may evaluate a limited problem and determine a simple management approach. Do not select 99212 simply because the visit appears short. The documentation must support the service actually performed.
Does 99212 Require a Certain History?
No. Current office and outpatient E/M rules do not require a specific number of history elements for selecting 99212 CPT code. The history should be medically appropriate for the problem being evaluated. The same principle applies to the examination. This change is important because older E/M rules relied heavily on prescribed history and examination components. Current office visit coding focuses instead on MDM or total time.
Does 99212 CPT code Require a Certain Examination?
No specific examination template is required for 99212 CPT code. The provider should perform and document the examination that is medically appropriate for the patient’s condition and the service provided. For example, a follow-up visit for a minor skin problem may require a focused examination of the affected area. A medication-management encounter may require a different examination depending on the patient’s condition and clinical circumstances. Documentation should reflect the actual service rather than a copied template.
99212 Time Requirement
When time is used to select 99212 CPT code, the applicable range is 10 to 19 minutes of total time on the date of the encounter. This is total physician or qualified healthcare professional time on the date of service that qualifies under the CPT E/M rules. The provider should document the total time when time is used as the basis for selecting the code. Time may include qualifying activities performed before, during, and after the encounter on the same date.
Examples can include:
- Preparing to see the patient
- Reviewing relevant records
- Performing the evaluation
- Counseling or educating the patient
- Ordering medications or tests
- Documenting clinical information
- Communicating with other professionals when permitted
- Performing other qualifying activities related to the encounter
The time should not be reported merely because a patient was physically present for 10 to 19 minutes. The documented total must represent qualifying provider time.
99212 vs 99211
It is important because the codes used for the new patient office visits will be 99202-99205.
| Feature | 99211 | 99212 |
|---|---|---|
| Patient | Established | Established |
| MDM | May not require physician/QHP-level MDM under applicable rules | Straightforward |
| Time | 5 to 9 minutes when time is used | 10 to 19 minutes |
| Provider involvement | May be minimal depending on circumstances | Requires appropriate E/M service |
| Typical use | Very limited established patient service | Straightforward evaluation and management |
It is not wise for a provider to simply code the office visit at 99212 if an established patient comes in. If the level of service is low and fails to qualify 99212, then 99211 could be considered provided all its criteria are fulfilled. Conversely, a more complex encounter may support 99213 or a higher-level code.
99212 vs 99213
Both codes apply to established patients, but they represent different levels of service.
| Feature | 99212 | 99213 |
|---|---|---|
| Patient status | Established | Established |
| MDM | Straightforward | Low |
| Time | 10 to 19 minutes | 20 to 29 minutes |
| Relative service level | Lower | Higher |
| Typical complexity | Straightforward | Low complexity |
The choice should be based on the documented MDM or total time. It should not be based on a diagnosis code alone. A chronic condition does not automatically justify 99213. Likewise, a simple diagnosis does not automatically limit the visit to 99212. The provider must document the actual work and management performed.
99212 CPT Code and Medical Necessity
All E/M claims require a diagnosis of medical necessity. In order to provide a claim it must demonstrate that the encounter was required to assess, manage, monitor or treat the patient’s condition or health care needs. Medical necessity is not just an issue of documentation of a diagnosis. History should link the patient’s condition to the services rendered.
For example, documentation may describe:
- The reason for the encounter
- Relevant clinical findings
- Conditions addressed
- Data reviewed
- Management decisions
- Treatment recommendations
- Follow-up instructions
- Medication decisions when applicable
The documentation should support why the service was reasonable and necessary.
99212 Modifier 25
The E/M code can have modifier 25 applied to it if an E/M service of a distinctly different nature is performed during the same day as another procedure or service. The additional work should be medically indicated and documented properly. The mere fact that there is some other service or condition does not qualify the use of modifier 25.
The E/M service needs to be distinct from the work performed in the other service. Additional E/M work supported by documentation. For instance, during a procedure, a patient might have a different problem assessed and addressed. If the new E/M service is appropriate, then 99212-25 might be the right code. Do not append modifier 25 automatically. It should be supported by the clinical circumstances and documentation.
99212 With a Procedure
An office visit and a procedure may occur on the same date. However, that does not automatically mean both services are separately payable. Code combinations should be checked against applicable National Correct Coding Initiative edits and payer policies. If the E/M service is separately identifiable and meets modifier requirements, modifier 25 may allow the E/M service to be reported with the procedure. The medical record should clearly distinguish the evaluation and management work from the procedure-related work.
99212 CPT code Documentation Requirements
Good documentation should support the service selected. When selecting 99212 by MDM, the record should support the medical decision making performed. When selecting the code by time, the record should support the total qualifying time.
A useful documentation structure can include:
| Documentation Area | What to Capture |
|---|---|
| Reason for visit | Why the patient was evaluated |
| Problems addressed | Conditions actually evaluated or managed |
| Assessment | Clinical findings and conclusions |
| Data | Records, tests, or other information reviewed |
| Management | Treatment, medication, testing, or follow-up decisions |
| Time | Total qualifying time when time selects the code |
| Medical necessity | Reason the service was needed |
| Follow-up | Relevant instructions or planned monitoring |
Avoid copying unrelated information from previous encounters. Documentation should accurately represent the current visit.
Common 99212 CPT code Billing Errors
Several errors can cause incorrect coding or claim problems.
Using 99212 for a New Patient
The 99212 CPT code is an established patient code. It should not be used when the patient meets the CPT definition of a new patient.
Choosing 99212 Only Because the Visit Was Short
Short duration does not automatically establish 99212. MDM may be used instead when the documentation supports the service.
Reporting 99212 Without Medical Necessity
Every billed E/M service should be supported by a medically necessary encounter.
Automatically Adding Modifier 25
Modifier 25 should not be applied because another service took place on the same date.
Using Old E/M Documentation Rules
Current office E/M coding does not require the historical key-component method for selecting the level.
Copying Templates Without Clinical Support
Templates can create documentation that does not accurately reflect the encounter. The record should describe the actual services performed.
Selecting the Code From Diagnosis Alone
A diagnosis does not independently determine the E/M level. The documented MDM or qualifying time must support the code.
99212 CPT Code Diagnosis Coding
The diagnosis code must contain a description of the condition, symptom or reason for the service. The selection of diagnosis may be based on the evaluation or management performed in the encounter. For example, an established patient follow-up may involve a chronic condition, a symptom, medication management, or another documented problem. Do not select a diagnosis simply because it commonly appears with 99212. The diagnosis should be supported by the clinical record.
99212 CPT Code RVU: 2026 Values
For 2026, the CMS July release lists the following relative value units for 99212:
| 2026 RVU Component | 99212 Value |
|---|---|
| Work RVU | 0.70 |
| Non-facility PE RVU | 1.02 |
| Facility PE RVU | 0.17 |
| Malpractice RVU | 0.06 |
| Total non-facility RVU | 1.78 |
| Total facility RVU | 0.93 |
RVUs do not represent a fixed reimbursement amount.Geographic adjustments and the applicable conversion factor are also considered for Medicare payments.
How Is 99212 CPT Code Reimbursement Calculated?
The reimbursement rate for 99212 does not have a single national rate. Physician fee schedule payment is determined under Medicare by combining a relative value (RVU) with a geographic practice cost (GPC) index and the appropriate conversion factor. A different locality may allow for different Medicare allowed amounts.
Commercial insurance reimbursement can differ even further because contracted rates, payer policies, network status, benefits, and geographic factors may affect payment. For example, the CMS-based 2026 data can be used to calculate a locality-specific Medicare payment, but that amount should not be presented as the universal payment for every 99212 claim.
99212 CPT Code Medicare Rule
99212 is an established patient office or outpatient E/M service which may be reimbursed under the Medicare Physician Fee Schedule if it is covered and properly reported. Medicare payment is determined by coverage rules, provider participation, locality, place of service and other claim specific factors.
The applicable payment framework and locality adjusted information is provided in the CMS Physician Fee Schedule. Due to deductible, coinsurance, sequestration, claim adjustments and other claim situations, actual claim payment may vary.
99212 and Telehealth
When applicable, an established patient E/M service may be furnished through telehealth when meeting applicable Medicare, CPT and payer requirements. Telehealth billing involves a number of factors, including keeping track of the payer’s rules, allowed practitioners, allowable services, place of service, modifiers, and documentation.
Do not assume that every 99212 service is automatically covered through telehealth. Commercial and government payer policies can differ. The claim should use the coding and telehealth reporting requirements applicable to the payer and date of service.
99212 CPT Code Examples
Example 1: Straightforward Follow-Up
A patient visits for the follow-up of a minor issue, after a previous visit. The provider assesses the issue, and takes a simple management decision. If a documented service is adequate for code 99212, the code could be used.
Example 2: Ten-Minute Established Visit
An established patient has a medically necessary office encounter. The provider performs qualifying activities totaling 12 minutes on the date of service. If the service otherwise meets the requirements, 99212 may be selected using time.
Example 3: More Complex Management
An established patient presents with several conditions requiring more extensive assessment and management. The provider does low level MDM to support a higher established patient code. In this case, 99213 might be more appropriate than 99212.
Example 4: Procedure and Separate E/M
An established patient undergoes a minor procedure and also presents with a separate problem. The provider performs significant, separately identifiable evaluation and management for that problem. If the documentation supports the additional service, 99212 with modifier 25 may be reported when appropriate.
Example 5: New Patient Encounter
A patient has not received a relevant professional service from the physician or same-specialty group within the applicable three-year period. A patient may be considered a new patient under the CPT definition. Then, the use of an established patient code (99212) would not be suitable.
99212 Billing Workflow
Use the following workflow to verify a 99212 claim before submission.
Step 1: Confirm Established Patient Status
Verify that the patient meets the CPT definition of an established patient. A physician has provided a professional service to the patient and the patient is a member of the same specialty and group of physicians within the last three years. In case the patient qualifies as a new patient, use 99202 to 99205 codes accordingly.
Step 2: Verify the Setting
Verify that the services took place in an office or other outpatient setting. The code 99212 is a family member of the established patient office and outpatient E/M family code. Other settings utilize other E/M code families.
Step 3: Identify the Problems Addressed
Review the assessment and plan to determine which problems the provider actually evaluated or managed. Do not count diagnoses that appear only in the medical record. A problem must be addressed through evaluation and/or treatment during the encounter.
Step 4: Determine Whether MDM Supports 99212
When MDM determines the level, 99212 requires straightforward medical decision making.
Review these three MDM elements:
- Number and complexity of problems addressed
- Amount and complexity of data reviewed and analyzed
- Risk of complications or morbidity and mortality from management
The overall MDM level must support the selected code. A diagnosis alone does not establish the E/M level.
Step 5: Check Time When Used for Code Selection
If time determines the code, verify 10 to 19 minutes of total qualifying time on the date of service.
Qualifying time can include:
- Preparing for the encounter
- Reviewing relevant records
- Performing the evaluation
- Counseling and education
- Ordering medications or tests
- Documenting the encounter
- Coordinating care when applicable
The provider should document the total qualifying time. Separate documentation of every individual task or minute is not required. If the provider is selected by MDM, then they are not required to meet or document 10 to 19 minutes.
Step 6: Compare 99212 With 99213
Check the documentation to ensure 99212 is the correct level of established patient.
| Code | MDM | Time |
|---|---|---|
| 99212 | Straightforward | 10 to 19 minutes |
| 99213 | Low | 20 to 29 minutes |
Avoid choosing 99213 because the patient has multiple diagnoses. Documented MDM or qualifying time has to be in support of the higher code.
Step 7: Review Same-Day Procedures
Check whether another procedure or service was reported on the same date. Decide if the E/M service was a distinct service from the procedure. Prior to reporting both services, review applicable NCCI edits and Payer specific rules.
Step 8: Evaluate Modifier 25
Modifier 25 is only used when the 99212 service is a significantly separately identifiable E/M service performed on the same date as another procedure/service. Avoid using modifier 25 if two services happen to be performed the same day. The documentation should support the additional evaluation and management work separately from the procedure-related work.
Step 9: Verify Diagnosis Coding
Verify that diagnosis codes are for the conditions, symptoms or reason(s) presented during the encounter. Eliminate diagnoses that were not assessed and treated. Utilize the most specific diagnosis that is supported by the documentation. The diagnosis should match the assessment and management noted in the note.
Step 10: Check Documentation
For an MDM-selected 99212, verify that the note supports straightforward MDM. For a time-selected 99212, verify that qualifying total time of 10 to 19 minutes is documented. The history and examination should be medically appropriate, but they do not determine the office E/M level under current guidelines. Office E/M level selection is based on MDM or total time.
Step 11: Apply Payer Requirements
After confirming CPT requirements, review applicable payer policies for:
- Coverage
- Modifiers
- Telehealth
- Documentation
- Frequency limits
- Medical necessity
- Claim edits
There may be a discrepancy between correct CPT selection and still have a problem with the reimbursement of a service because the payment requirements were not met.
Step 12: Perform a Final Claim Review
Before submission, confirm that the following agree:
- Patient status
- Place of service
- CPT code
- MDM or total time
- Diagnoses
- Modifiers
- Same-day services
- Documentation
- Payer requirements
A 99212 claim should be an accurate representation of the service recorded in the medical record.
Key Takeaways
The code 99212 is used for any established patient office or other outpatient E/M service. The service is normally considered simple medical decision making or a total time of 10 minutes to 19 minutes when the time is spent selecting a code.
The “old” history and examination key-component system is not relevant to current office E/M coding. Providers, however, choose the appropriate level by use of MDM or total time, with documentation to support medical necessity.
For 2026, 99212 CPT code carries 0.70 work RVUs, 1.02 non-facility PE RVUs, 0.17 facility PE RVUs, and 0.06 malpractice RVUs. That comes to a total of 1.78 non-facility RVUs (or 0.93 facility RVUs). Accurate patient-status verification, proper level selection, all documentation, etc., and correct use of modifiers are all important elements of clean 99212 billing.
