Defining ‘New Patient’

New Patient CPT Code Range 99202 – 99205

The new Patient CPT code range is used to describe the initial visit with a healthcare provider. These codes were last revised in the year 2021 by the AMA to better reflect the level of complexity and time required for a visit. The new patient CPT code range is as follows:

CPT Code 99202

This code describes a level 2 new patient visit that requires a low level of medical decision-making. The typical time for this visit is 20 minutes. Documentation requirements for new patient CPT code 99202 are as follows:

• History: Expanded problem-focused history
• Exam: Expanded problem-focused exam
• Medical decision-making: Straightforward complexity
• Typical face-to-face time: 15-29 minutes

CPT Code 99203

This code describes a level 3 new patient visit that requires a moderate level of medical decision-making. The typical time for this visit is 30 minutes. Documentation requirements for new patient CPT code 99203 are as follows:

• History: Detailed history
• Exam: Detailed exam
• Medical decision-making: Low complexity
• Typical face-to-face time: 30-44 minutes

CPT Code 99204

This code describes a level 4 new patient visit that requires a high level of medical decision-making. The typical time for this visit is 45 minutes. Documentation requirements for new patient CPT code 99204 are as follows:

• History: Comprehensive history
• Exam: Comprehensive exam
• Medical decision-making: Moderate complexity
• Typical face-to-face time: 45-59 minutes

CPT Code 99205

This code describes a level 5 new patient visit that requires a comprehensive level of medical decision-making. The typical time for this visit is 60 minutes. Documentation requirements for new patient CPT code 99205 are as follows:

• History: Comprehensive history
• Exam: Comprehensive exam
• Medical decision-making: High complexity
• Typical face-to-face time: 60-74 minutes

It’s important to note that CPT code selection is not just based on the typical face-to-face time alone, but also on the level of history, exam, and medical decision-making documented in the medical record. The typical face-to-face times listed here are just guidelines and should not be the sole factor in determining the accurate code from the new patient CPT code range. The time listed for each code is an average and can vary based on the complexity of the patient’s medical history, the number of complaints or symptoms, and other factors. Providers should use their clinical judgment to determine the appropriate code based on the level of medical decision-making required.

New Patient vs. Established Patient

Previously, distinguishing between new and established patients was simple. A new patient was someone who had not been seen before or did not have a current medical record. However, due to changes in healthcare delivery, this differentiation has become more complicated. As mentioned above, a new patient is someone who has not received professional services from the physician or another physician in the same specialty and group practice within the last three years, while an established patient has received such services within the last three years.

Another important distinction between the new patient and established patient codes is that the new patient code range (99202-99205) mandates all three key components (history, examination, and medical decision-making) to be met, whereas the established patient code range (99211-99215) requires only two of the three key components to be met. Since the requirements for coding problem-oriented new patient visits are more rigorous, there may be instances where the same service components would result in an established patient code with more RVUs than the appropriate new patient code.

Defining ‘Professional Services’ and ‘Group Practice’

Defining ‘Professional Services’

‘Professional Services’ refer to those medical services that are provided by a physician or qualified healthcare provider in person and reported by a specific CPT code. The key phrases are ‘face-to-face’ and ‘reported by a specific CPT code(s).’ This definition is important because it helps practices to determine whether a patient is new or established, based on whether the physician or provider has provided a face-to-face service to that patient within the last three years. If the physician or provider has not provided a face-to-face service to the patient within the last three years, then the patient is considered a new patient and can be billed using the appropriate code from the new patient CPT code range.

Defining ‘Group Practice’

‘Group Practice’ refers to a healthcare organization or facility where multiple healthcare providers work together, such as a medical group or clinic. In group practices, the definition of a ‘new patient’ can be more complex than in solo practices because the patient may have seen another provider within the same group. The critical element in this scenario is the specialty designation of the healthcare provider. Suppose a patient has been receiving care from a pediatrician within your practice regularly. If the patient reaches the age of 18 and decides to transfer care to a family physician within the same practice, they would be considered a new patient.

How does new patient CPT code range impact your practice?

The new patient CPT code range aims to more accurately reflect the complexity of the visit and the amount of time required to complete it. This can have an impact on your practice in several ways.

• First, the new codes may require you to adjust your documentation practices to ensure that you are accurately capturing the level of medical decision-making required for a visit. This may include updating your electronic health record (EHR) templates or training staff on the new codes and documentation requirements.
• Second, the new codes may impact reimbursement rates for new patient visits. Insurance companies may adjust their reimbursement rates based on the level of complexity of the visit, which could result in higher or lower reimbursement rates for your practice.
• Finally, the new codes may impact patient satisfaction and retention. Patients may be more likely to return to a provider who takes the time to thoroughly assess their medical history and develop a comprehensive treatment plan. By accurately capturing the complexity of the visit with the new CPT codes, you can demonstrate to patients that you are providing high-quality care.

In conclusion, the new patient CPT code range is an important update for primary care providers. By accurately reflecting the level of complexity and time required for the initial visit, these codes can help providers better document their services, improve reimbursement rates, and enhance patient satisfaction and retention. As a primary care provider, it’s important to stay up-to-date on coding changes to ensure that your practice is providing high-quality care and maximizing revenue opportunities.

In case you find it difficult to accurately use the new patient CPT code, we can assist you. Medical Billers and Coders (MBC) is a leading revenue cycle management company providing complete medical billing and coding services. We can assist you in the accurate selection of CPT codes as per the insurance company’s guidelines. We take complete ownership for accurate claim submissions for all major insurance companies like Medicare, Medicaid, and commercial insurance companies in your area.

Our expertise in primary care billing ensures maximum insurance reimbursements while following compliance with regulatory requirements. To know more about our primary care billing services, email us at: [email protected] or call us at: 888-357-3226.

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