New Patient Office Visit: Coverage and Documentation Requirements

Published 06/02/2023

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 E/M Services — Overview of Key Components
The key components of E/M including those services billed for New Patient Office Visit (E/M) Services:

  1. History
  2. Examination
  3. Medical decision-making

New Patient Office Visit (E/M) Services (CPT® 99201–99205) — Documentation Requirements

CPT® Code
Description
Documentation Requirements
99201
Typically 10 minutes
  • Problem-focused history
  • Problem-focused exam
  • Straightforward medical decision-making

(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
  • Expanded problem-focused history
  • Expanded problem-focused exam
  • Straightforward medical decision-making

(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
  • Detailed history
  • Detailed examination
  • Low-complexity medical decision-making

(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
  • Comprehensive history
  • Comprehensive examination
  • Moderate medical decision-making

(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
  • Comprehensive history
  • Comprehensive examination
  • High complexity medical decision-making

(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

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 M (JM). 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 JM.

Example of eCBR Results from eServices

eCBR Lookup New Patient Office Visits Screen Display

Please be aware that the information contained within this CBR is not intended to be punitive or an indication of fraud. Rather, it is intended to be proactive communication that will assist you in identifying potential billing issues and help you with performing a self-audit of your conformity with Medicare guidelines.


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