News You Can Use: New Patient Office Visits


Medical record documentation is required to record pertinent facts, findings and observations about an individual's health history including past and present illnesses, examinations, tests, treatments and outcomes. The medical record chronologically documents the care of the patient and is an important element contributing to high quality care.

The medical record facilitates:

  • The ability of the physician and other health care professionals to evaluate and plan the patient’s immediate treatment and to monitor his or her health care over time
  • Communication and continuity of care among physicians and other health care professionals involved in the patient's care
  • Accurate and timely claims review and payment
  • Appropriate utilization review and quality of care evaluations
  • Collection of data that may be useful for research and education

An appropriately documented medical record can reduce many of the denials and errors associated with claims processing and may serve as a legal document to verify the care provided, if necessary. Selecting the code that best represents the service furnished is key to decreasing claim denials. Billing Medicare for an E/M service requires the selection of a Current Procedural Terminology (CPT) code that best represents:

  • Patient type
  • Setting of service and
  • Level of E/M service performed

For purposes of billing for E/M services, patients are identified as either new or established, depending on previous encounters with the provider.

A new patient is defined as an individual who has not received any professional services from the physician/nonphysician practitioner (NPP) or another physician of the same specialty who belongs to the same group practice within the previous three years.

An established patient is an individual who has received professional services from the physician, NPP or another physician of the same specialty who belongs to the same group practice within the previous three years. Billing Medicare for an E/M service requires the selection of a current procedural.

Interpret the phrase "new patient" to mean a patient who has not received any professional services, i.e., E/M service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous three years.

For example, if a professional component of a previous procedure is billed in a three year time period, e.g., a lab interpretation is billed and no E/M service or other face-to-face service with the patient is performed, then this patient remains a new patient for the initial visit.

An interpretation of a diagnostic test, reading an X-ray or EKG, etc., in the absence of an E/M service or other face-to-face service with the patient does not affect the designation of a new patient.

99201

Office or other outpatient visit CPT code 99201 is used for the evaluation and management of a new patient, which requires these three key components:

  1. A problem focused history;
  2. A problem focused examination; and
  3. A straightforward medical decision

Counseling and/or coordination of care with other physicians, other qualified health care professionals or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs.

Usually, the presenting problem(s) are self-limited or minor. Typically, 10 minutes are spent face –to-face with the patient and/or family.

 99202

Office or other outpatient visit CPT code 99202 is used for the evaluation and management of a new patient, which requires these three key components:

  1. An expanded problem focused history
  2. An expanded problem focused examination; and
  3. A straightforward medical decision

Counseling and/or coordination of care with other physicians, other qualified health care professionals or agencies are provided consistent with the nature of the problem(s) and the patient’s and or family’s needs.

Usually, the presenting problem(s) are of low to moderate severity. Typically, 20 minutes are spent face-to-face with the patient and/or family.

99203

Office or other outpatient visit CPT code 99203 is used for the evaluation and management of a new patient, which requires these three key components:

  1. A detailed history;
  2. A detailed examination; and
  3. Medical decision making of low complexity

Counseling and/or coordination of care with other physicians, other qualified health care professionals or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs.

Usually, the presenting problem(s) are of moderate severity. Typically, 30 minutes are spent face–to-face with the patient and/or family.

99204

Office or other outpatient visit CPT code 99204 is used for the evaluation and management of a patient, which requires the following three components:

  1. A comprehensive history;
  2. A comprehensive examination; and
  3. Medical decision making of moderate complexity

Counseling and/or coordination of care with other physicians, other qualified health care professionals or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs.

Usually, the presenting problem(s) are of moderate to high severity. Typically, 45 minutes are spent face–to-face with the patient and/or family.

99205

Office or other outpatient visit CPT code 99205 is used for the evaluation and management of a patient, which requires the following three components:

  • A comprehensive history
  • A comprehensive examination; and
  • Medical decision making of high complexity

Counseling and/or coordination of care with other physicians, other qualified health care professionals or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs.

Usually, the presenting problem(s) are of moderate to high severity. Typically, 60 minutes are spent face–to-face with the patient and/or family.

Resource: Evaluation and Management (E/M) Visits.





Last Updated: 08/03/2020