Office visit evaluation and management codes split between new and established patients. New patients (no service from provider/group in 3 years) bill CPT 99202-99205; established patients bill 99211-99215. New patients require documentation of all three key components (history, exam, MDM) to the specified level. Established patients use MDM complexity or time-based selection (no history/exam requirement as of 2021). 99214 is the most common level for established office visits, representing moderate complexity visits with common chronic diseases and routine medication management. CPT code selection determines reimbursement—higher codes mean higher payments, but accurate coding is essential to avoid audit risk.
For new patients, determine the level by selecting the LOWEST of history, exam, and MDM. Document all three to the required depth. 99202: straightforward (minimal history, limited exam, simple MDM). 99203: low to moderate (brief history, focused exam, straightforward MDM). 99204: moderate to high (detailed history, exam, moderate MDM). 99205: high (comprehensive history, detailed exam, high MDM). For established patients, use MDM complexity OR documented time, not both. 99211: minimal (routine follow-up, stable chronic disease, minor problems). 99212: low (simple problems, 10-19 min). 99213: low-moderate (2 diagnoses, 20-29 min). 99214: moderate (3+ diagnoses, medication adjustment, lab review, 30-39 min). 99215: high (complex, multiple chronic unstable, 40+ min).
Office E/M visits do not require prior authorization. Payers pay directly based on the code submitted. However, audits are common for high-level coding (99204, 99205 for new patients; 99215 for established). Most payers expect: established patients average 40-60% at level 99214, 20-30% at 99213, less than 10% at 99215. New patient averages vary by specialty but typically 40-50% at 99203, 30-40% at 99204, 10-20% at 99202. Suspicious patterns (all 99215s, or very high new patient levels) trigger audits and recovery demands. Code accurately to what is documented.
E/M office visits are not bundled with most procedures. If a procedure (injection, minor surgery, wound repair) is performed during the visit, bill the E/M with modifier 25 on the office visit code to indicate the E/M is a distinct service above the procedure. The procedure is billed separately. Do not bundle preventive care (99381-99397) with problem-focused E/M on the same day without modifier 25 and separate documentation. If prolonged services (99354-99355) occur, bill the appropriate office E/M plus the prolonged code.
For new patients, document history (chief complaint, history of present illness, review of systems, past medical/surgical history, family history, social history), physical exam findings (vital signs, focused or comprehensive exam by system), and MDM (assessment, differential diagnosis, plan, risk factors). For established patients, document chief complaint, relevant history, exam findings, and MDM (diagnosis, management, plan). Time-based coding requires documentation of total time including face-to-face, chart review, and care coordination. Document MDM clearly: list diagnoses and their status, reference labs or imaging reviewed, note medication changes and reasoning, document risk factors considered. Specificity is key—vague notes result in downcoding.
After the first visit, the patient is established for all future visits. Use 99211-99215 codes. The transition occurs after the initial new patient visit is complete. Do not bill new patient codes twice.
If they haven't received any professional service from the provider or the group in 3 years, they are new. If they were seen within 3 years (even by another provider in the group), they are established. This rule is strict; compliance is audited closely.
No. Code based on documented complexity and time (or MDM), not on the reimbursement desired. A simple, straightforward visit should code at 99212-99213 even if you spent 30 minutes. Payers audit high-code claims and recoup overpayment if documentation doesn't support the level.
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