CPT Code 99202: New patient office visit billing guide 2026

Key Takeaways

CPT code 99202 covers new patient office visits requiring straightforward MDM or 15-29 minutes of total time on the date of the encounter.

Code 99201 was deleted January 1, 2021 – 99202 is now the entry-level new patient E/M code under post-2021 AMA guidelines.

Common denials stem from missing documentation of the new patient status, incomplete MDM elements, or modifier misuse.

Pabau’s claims management software automates claim submission and flags incomplete E/M documentation before a claim leaves the practice.

CPT code 99202 is the entry-level new patient outpatient E/M code under current AMA guidelines. This guide covers its documentation requirements, MDM and time-based selection criteria, 2026 reimbursement rates, applicable modifiers, and denial prevention strategies for outpatient billing teams.

CPT code 99202: Definition, criteria, and clinical use

CPT code 99202 is the lowest-complexity new patient outpatient visit in the current AMA CPT code set. Its documentation requirements are precise, and incomplete MDM elements or missing new patient status confirmation are the leading causes of denial.

The official AMA descriptor reads: Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 15-29 minutes of total time is spent on the date of the encounter.

Two pathways exist for selecting CPT code 99202: straightforward MDM or total time of 15-29 minutes. Either qualifies, and documentation must support whichever method the provider uses.

Psychiatrists and nurse practitioners use CPT code 99202 frequently for initial low-complexity evaluations. Primary care physicians apply it to brief new patient assessments for minor acute complaints.

Chiropractors and other specialists use it when the presenting problem involves minimal risk and a limited number of diagnoses. The code works across psychiatry EMR software workflows and most outpatient specialty settings where new patient E/M is billable.

Who qualifies as a “new patient”?

A new patient is one who has not received any professional services from the same physician or qualified health care professional (QHP), or another physician or QHP of the exact same specialty and subspecialty in the same group practice, within the past three years.

The CPT code set defines this three-year rule at the group-practice level, not just for the individual provider. American Academy of Family Physicians guidance corroborates that application.

A few edge cases create confusion. If a patient saw a physician in a different specialty within the same group, the encounter may still qualify as a new patient visit. Emergency department visits and inpatient consults typically do not reset the three-year clock for outpatient new patient coding.

Medical decision making (MDM) criteria for 99202

Straightforward MDM is required for CPT code 99202. The AMA defines it across three elements, and the encounter must meet or exceed the straightforward threshold in at least two of the three.

Two of the three columns must meet or exceed the straightforward threshold to support 99202. Providers often underestimate the data element – if external records were reviewed, a test was ordered, or an independent interpretation was performed, the visit may qualify for a higher-level code such as CPT code 99203 (low MDM).

Practical examples of straightforward MDM include: a new patient presenting with a minor skin rash requiring only OTC hydrocortisone, a first-visit pediatric weight check with no chronic conditions identified, or an initial chiropractic assessment for an acute minor musculoskeletal strain with no prior imaging ordered. Providers coding coaching CPT codes for low-complexity behavioral health visits sometimes encounter similar MDM thresholds.

Time-based coding for CPT code 99202: The 15–29 minute rule

Post-2021 AMA guidelines allow time as a standalone basis for E/M code selection. For CPT code 99202, total time on the date of the encounter must fall between 15 and 29 minutes. Total time includes all time the provider spends on that patient’s care on that date, not just face-to-face contact.

• Included in total time: preparation, reviewing records before the visit, taking history, performing the physical exam, ordering tests, documenting the encounter, coordinating care, and counseling the patient or family
• Excluded from total time: travel time, time spent on work unrelated to the patient, and staff time (e.g., nursing intake conducted separately)

Providers must document the total time spent and the activities performed. “30 minutes spent” without detail does not meet the standard. A concise note stating “20 minutes of total time spent on this encounter including chart review, examination, documentation, and care coordination” satisfies the requirement.

If total time crosses 29 minutes but MDM remains straightforward, the time pathway bumps the code to CPT code 99203 (30-44 minutes). Providers should select the pathway that yields the most accurate code for the work performed, whether that is MDM or time.

Using the ADHD screening CPT codes as a parallel example, time-based selection follows the same total-time-on-date principle. Behavioral health providers may also find our Internet Addiction Test template useful for structuring low-complexity new patient assessments that fall within the 99202 time window.

CPT code 99202 vs. adjacent new patient E/M codes (99203–99205)

Selecting the correct code from the 99202-99205 range matters for reimbursement accuracy and audit readiness. The table below compares the four active new patient outpatient E/M codes.

CPT code 99201 no longer exists. It was deleted effective January 1, 2021 as part of the AMA’s E/M coding guideline revision, which CMS adopted in the 2021 Medicare Physician Fee Schedule. CPT code 99202 is now the entry-level new patient code. Any documentation or superbill still referencing 99201 will result in an automatic claim denial.

The difference between CPT code 99202 and 99203 is a single complexity step in MDM and 15 minutes in time. Providers who spend 30 minutes on a minor complaint may legitimately bill 99203, even if the MDM stays straightforward. Time and MDM are independent selection pathways.

Similar code range logic applies when billing IVF CPT codes, where precise code selection affects reimbursement significantly. Providers supporting patients with nutritional concerns may also encounter ICD-10 code E54 (ascorbic acid deficiency) during new patient assessments, which pairs with a straightforward MDM determination under 99202.

Documentation requirements for CPT code 99202 post-2021

The 2021 AMA guideline changes eliminated the three-key-components requirement (history, exam, MDM) that governed E/M coding before January 1, 2021. Under current rules, the visit note for CPT code 99202 must document:

• A medically appropriate history and/or examination (level of detail left to the provider’s clinical judgment)
• Either: straightforward MDM with all three columns documented, OR total time on the date of the encounter with activities enumerated
• The patient’s new patient status (confirm no professional services from the same group/specialty/subspecialty in the past three years)

The “medically appropriate” standard gives providers flexibility – a focused history for a rash is appropriate; a complete review of systems for the same rash is not required. However, the chart must show some history and/or examination was performed. A note that jumps directly to assessment and plan with no clinical context will not survive an audit.

For time-based coding, the note should include a start/end time or a clear statement of total time (e.g., “22 minutes of total provider time on date of encounter”). Pabau’s claims management software flags incomplete E/M fields before a claim is submitted, reducing the risk of documentation-driven denials on CPT code 99202 visits.

Audit risk and OIG focus areas for 99202

The Office of Inspector General (OIG) monitors E/M coding patterns, including new patient visit frequency and upcoding trends. Practices with an unusual concentration of 99204 and 99205 codes relative to 99202 and 99203 draw scrutiny. Equally, practices that routinely bill 99202 for encounters clearly documented as moderate complexity face downcoding risk on audit.

Keep documentation proportional to the code. A 99202 note should reflect a straightforward visit. A note spanning multiple pages with extensive problem lists and data reviews signals a higher-complexity encounter and creates inconsistency between the note and the code billed.

Good medical practice scheduling software helps practices allocate appropriate appointment time for each code level, reducing the risk of time mismatches. For practices providing cosmetic or post-procedure visits alongside routine E/M, the lip blushing aftercare instructions template is an example of structured documentation that keeps procedure records separate from E/M notes, supporting modifier 25 defensibility.

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Reimbursement rates for CPT code 99202 in 2026

Medicare reimbursement for CPT code 99202 varies by geographic region, facility vs. non-facility setting, and whether the provider participates in Medicare. The CMS Physician Fee Schedule lookup tool provides current, location-specific payment amounts. Always verify rates there rather than relying on published estimates, which go out of date when CMS adjusts conversion factors mid-year.

For initial hospital inpatient visits, see also our guide on CPT code 99222, which follows similar MDM and time-based selection logic.

As a general orientation (not a guarantee of payment), non-facility Medicare reimbursement for CPT code 99202 varies by location and year. The CMS conversion factor is adjusted annually, so any published dollar figure may be out of date — always verify current 2026 rates via the CMS lookup tool.

Rates are higher in metropolitan areas with elevated geographic practice cost indices (GPCIs). Facility rates, such as hospital outpatient departments and ambulatory surgical centers, are typically lower than non-facility rates for the same code.

For RVU values and location-adjusted reimbursement estimates, the CMS lookup tool allows providers to enter a code and zip code for a calculated estimate using CMS data and location multipliers.

Commercial and Medicaid rates for CPT code 99202

Commercial payers typically reimburse above Medicare rates, though the difference varies by contract. Medicaid rates for CPT code 99202 vary significantly by state. Louisiana Medicaid, for example, requires modifier TH on CPT codes 99202–99205 in specific circumstances and has distinct reimbursement policies for new patient visits billed within three years of a prior visit from the same provider.

Practices operating in multiple states or serving mixed payer populations should cross-reference code descriptions and crosswalks via the relevant payer contract or portal, then verify rates directly. Mental health EMR systems built for multi-payer environments help practices track reimbursement by payer and flag rate discrepancies at the code level.

Practices billing injectables alongside E/M services can review the abobotulinumtoxinA (Dysport) HCPCS billing guide for an example of how modifier 25 documentation applies when a procedure accompanies a new patient visit.

Modifiers for CPT code 99202 and billing errors to avoid

Two modifiers appear most frequently alongside CPT code 99202. Knowing when each applies — and when they create audit risk — protects practices from denials and OIG scrutiny.

Modifier 25 is the most commonly misused modifier on E/M claims. Appending it to CPT code 99202 when no separate procedure was performed, or when the E/M documentation is not distinct from the procedure note, creates a claim that will not survive a focused audit.

The E/M note must stand alone and document work performed above and beyond what the procedure requires. Keeping modifier 25 documentation in a separate note section, rather than embedded in the procedure note, is a practical safeguard against denials. The same documentation-separation principle applies to established-patient visits — see our CPT code 99212 documentation guide for a comparable example.

Telehealth billing for 99202

CPT code 99202 may be billed for telehealth visits when the service is delivered via synchronous audio and video technology. The visit must meet the same MDM or time criteria as an in-person encounter. Modifier 95 is required.

Some payers also require place of service code 02 (telehealth provided other than in patient’s home) or 10 (telehealth provided in patient’s home).

Audio-only telehealth does not qualify for CPT code 99202. Medicare has specific provisions for audio-only services that use separate codes. Confirm each payer’s telehealth policy before billing 99202 with modifier 95 to a new patient who was seen remotely. Practices using telehealth software integrated with their billing workflow can document place of service automatically, reducing modifier selection errors.

CPT code 99202 denial prevention checklist

The most common denial triggers for CPT code 99202 fall into four categories. A pre-submission review against this checklist catches most of them before they reach the payer.

• New patient status confirmed: No professional services from any provider in the same group/specialty/subspecialty within the past three years. Document the check in the billing notes.
• MDM or time documented, not just implied: If using MDM, all three elements (problems, data, risk) must appear explicitly in the note. If using time, total time and activities must be stated.
• History and/or examination present: Even under post-2021 rules, some clinical context is required. A note with only assessment and plan will not hold up.
• Modifier 25 justified independently: If modifier 25 is appended, the E/M documentation must describe work separate from the procedure. Review both notes before submission.
• Code 99201 removed from superbill: If your practice still has 99201 on any superbill, template, or billing shortcut, remove it. It was deleted in 2021 and causes automatic denials.
• Telehealth modifier present when applicable: Modifier 95 and correct place of service code must appear on all telehealth claims for CPT code 99202.

Practices using practice management software with built-in billing rules can automate several of these checks. For wearable device billing that may accompany new patient assessments, the HCPCS code K0606 wearable defibrillator guide demonstrates how separate supply codes interact with E/M claims. Payer-specific edits, modifier validation, and date-of-service logic can be applied at claim creation rather than after a denial arrives.

How Pabau supports accurate CPT code 99202 billing

Revenue cycle management for new patient E/M visits depends on documentation accuracy at the point of care, not correction after a denial. Pabau’s claims management tools build compliance checks into the submission workflow. Required fields for E/M documentation are validated before a claim is generated, so what the provider documents matches what the payer receives.

Practices managing mixed payer populations, telehealth and in-person new patient visits, and multi-provider groups benefit from a system that tracks new patient status, enforces modifier rules, and surfaces denial patterns by code. For outpatient primary care, psychiatry, chiropractic, and functional medicine practices billing CPT code 99202 frequently, consistent documentation tooling produces measurable improvements in first-pass claim acceptance rates.

Practices focused on functional medicine software workflows see similar gains when E/M documentation is structured at the point of care rather than reconstructed later. Practices offering eating disorder recovery services can use the eating disorder worksheet template to capture structured intake data that supports MDM documentation at the 99202 level.

The direct primary care EHR model, which often de-emphasizes traditional E/M billing, still produces encounters that must be correctly coded when patients have insurance coverage for specific services. Accurate CPT code 99202 documentation protects the practice regardless of the care delivery model.

Continue your research

Need a claims management overview for your specialty? Pabau claims management software covers end-to-end billing workflow from documentation to submission and denial tracking.

Running a psychiatry or mental health practice? Mental health EMR built for outpatient settings where new patient E/M coding is a daily workflow.

Looking for a compliance and audit resource? HIPAA compliance for medical offices covers documentation standards that overlap with E/M audit readiness.

Conclusion: Getting CPT code 99202 right

CPT code 99202 denials are largely preventable. The code covers a new patient visit with minimal complexity or 15–29 minutes of total time, but claim rejections consistently trace back to incomplete MDM documentation, missing new patient status confirmation, or leftover references to the deleted CPT code 99201.

Practices that build documentation checks into the point-of-care workflow, rather than reviewing after a denial, see the biggest improvements in first-pass acceptance rates. Pabau’s built-in claims management validates E/M fields before submission and tracks denial patterns by code. To see how it works for new patient outpatient billing, book a demo.

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