New Patient Office Visit (CPT Codes 99201-99205): Coverage and Documentation Requirements
This Comparative Billing Report (CBR) focuses on physicians who submit claims for New Patient Office Visit (E/M) Services (CPT codes 99201-99205). CBR information is one of the many tools used to assist individual providers to become proactive in addressing potential billing issues and performing internal audits to ensure compliance with Medicare guidelines.
For your personalized New Patient Office Visit (E/M) Services (CPT codes 99201-99205) eCBR results, log on to eServices.
New Patient Office Visit (E/M) Services (CPT Codes 99201-99205) - Overview of Key Components
The key components of E/M including those services billed for New Patient Office Visit (E/M) Services
- History
- Examination
- Medical decision-making
New Patient Office Visit (E/M) Services (CPT 99201-99205) - Documentation Requirements
|
CPT Code
|
Description
|
Documentation Requirements
|
|---|---|---|
|
99201
|
Typically 10 minutes
|
(Based on straightforward medical decision making)
Minimal number of diagnoses or management options;
None or minimal amount and/or complexity of data to be reviewed;
Minimal risk of significant complications, morbidity and/or mortality or
Limited number of diagnoses or management options;
Limited amount and/or complexity of data to be reviewed; low risk of significant complications, morbidity and/or mortality
|
|
99202
|
Typically 20 minutes
|
(Based on straightforward medical decision making)
Minimal number of diagnoses or management options;
None or minimal amount and/or complexity of data to be reviewed;
Minimal risk of significant complications, morbidity and/or mortality or
Limited number of diagnoses or management options;
Limited amount and/or complexity of data to be reviewed; low risk of significant complications, morbidity and/or mortality
|
|
99203
|
Typically 30 minutes
|
(Based on low- complexity medical decision making)
Minimal number of diagnoses or management options;
None or minimal amount and/or complexity of data to be reviewed;
Minimal risk of significant complications, morbidity and/or mortality or
Limited number of diagnoses or management options;
Limited amount and/or complexity of data to be reviewed; low risk of significant complications, morbidity and/or mortality
|
|
99204
|
Typically 45 minutes
|
(Based on moderate medical decision making)
Multiple number of diagnosis or management options;
Moderate amount and/or complexity of data to be reviewed;
Moderate risk of significant complications, morbidity and/or mortality
|
|
99205
|
Typically 60 minutes
|
(Based on high complexity medical decision making)
Extensive number of diagnosis or management options;
Extensive amount and /or complexity of data to be reviewed;
High risk of significant complications, morbidity and/or mortality
|
Education Resources:
The Provider Outreach and Education (POE) team has developed a web-based training to address the issues pertinent to New Patient Office Visit codes. Your practice is being advised to view the WBT using the following link: Interactive Tool: New Patient Office Visits Module
Methods:
The metrics reviewed in this CBR are the proportion of billing for each HCPCS code in the E/M grouping with comparisons to peers within the state and Jurisdiction J (JJ). This report is an analysis of Medicare Part B claims extracted from the Palmetto GBA data warehouse. The analysis shows the portions of your New Patient Office Visit family of codes (CPT codes 99201-99205) claims at each level compared to your peers in JJ.
Example of eCBR Results from eServices:
