99202 CPT Code Explained: Definition, Billing & Reimbursement Guide
At a Glance
- New patient, office or outpatient visit
- Straightforward medical decision-making
- Total visit time: 15–29 minutes (time-based billing)
- Medicare national rate: ~$76–$93 (varies by locality)
- Requires medically necessary documentation
- Cannot be billed for established patients
What Is the 99202 CPT Code?
CPT code 99202 is a Current Procedural Terminology (CPT) code used to bill for a new patient office or outpatient visit at the second level of complexity — what the American Medical Association (AMA) classifies as a “straightforward” evaluation and management (E/M) encounter.
In plain terms: a provider sees a new patient for the first time, evaluates a relatively uncomplicated medical concern, makes a clinical decision, and documents the encounter. The 99202 code is used to communicate all of that to an insurance payer in a standardized, billable format.
“New patient” carries a specific definition in the CPT system. A patient is considered new if they have not received any professional services from the physician, or from another physician of the same specialty and subspecialty who belongs to the same group practice, within the past three years. If any qualifying visit has occurred within that window, the patient is an established patient and 99202 does not apply — you would instead use codes from the 99211–99215 series.
Common Pitfall
Billing 99202 for an established patient — even unintentionally — constitutes upcoding and can trigger payer audits, claim denials, or compliance penalties. Always verify patient status before selecting a new-patient code.
The Three Pillars: What Determines Code Selection
Since the AMA’s sweeping E/M coding changes took effect in January 2021, two pathways exist for selecting the appropriate level of service for office-based E/M visits: medical decision-making (MDM) complexity or total time. Both pathways are equally valid, and providers should choose whichever best reflects the work performed.
Pathway 1 — Medical Decision-Making (MDM)
Under this pathway, 99202 requires “straightforward” MDM. The AMA defines straightforward MDM across three elements — number and complexity of problems, amount and/or complexity of data reviewed, and risk of complications and/or morbidity or mortality.
All three elements must independently support the “straightforward” level — the code selection is based on at least two of the three meeting that threshold. Common clinical scenarios that typically fit include visits for a new patient presenting with uncomplicated acute sinusitis, a minor skin laceration, mild contact dermatitis, or a simple urinary tract infection with no complicating factors.
Pathway 2 — Total Time on the Date of Service
The time-based billing pathway was significantly clarified in the 2021 revisions. Total time now includes all time spent by the billing provider on the date of the encounter — not just face-to-face time. This encompasses pre-visit chart preparation, the face-to-face encounter, ordering tests or medications, documenting the visit, and coordinating care.
For 99202, the required total time is 15–29 minutes. If the encounter takes 30 minutes or more but still involves a new patient, the next level code (99203) would be more appropriate.
Documentation Tip
When billing by time, document the total time spent and what activities were performed. A note stating “Total time: 18 minutes, including chart review, history taking, examination, and documentation” satisfies the requirement. You do not need to itemize each activity’s duration separately.
Documentation Requirements
One of the most significant changes from the 2021 E/M revisions is that the history and physical examination no longer drive code selection. They must still be medically appropriate and documented — but their extent no longer has to meet a rigid element-count checklist. The provider determines what history and exam are clinically indicated, and the documentation should reflect that judgment.
What remains critical for 99202 is clear documentation of the MDM elements or total time, whichever pathway is used. For MDM, the note should specifically articulate the nature of the presenting problem, any data reviewed or ordered, and the risk involved in the management plan. Vague or templated notes that do not connect clinical details to decision-making remain a major audit vulnerability.
Key Documentation Checklist
- Patient identified as “new” (no qualifying encounter in past 3 years from this provider/group/specialty)
- Chief complaint and relevant history documented (extent medically appropriate)
- Physical examination documented (extent medically appropriate)
- Assessment and plan clearly stated
- MDM elements support “straightforward” level, OR total time is documented as 15–29 minutes
- Provider signature and credentials present
- Date of service matches the claim
Reimbursement Rates: What to Expect
Reimbursement for 99202 varies based on payer, geographic location, and whether the visit is conducted in a facility or non-facility setting. The distinction matters: a non-facility rate (e.g., a private office) is higher than a facility rate (e.g., a hospital outpatient department), because in a facility setting, the facility itself bills separately for overhead and resources.
Medicare reimbursement is calculated using Relative Value Units (RVUs). The 99202 code carries a work RVU of approximately 0.93 (non-facility total RVU around 2.06). The actual payment is the total RVU multiplied by the Medicare Conversion Factor, which is updated annually. Providers should always verify current rates through the CMS Physician Fee Schedule Lookup Tool, as conversion factors change each calendar year.
“Accurate code selection is not just a billing function — it is a clinical documentation discipline that begins at the point of care.”
Comparing 99202 to Adjacent Codes
Understanding where 99202 sits within the new patient office visit code family helps prevent both undercoding (leaving revenue on the table) and upcoding (a compliance risk). Here is how it compares to the codes on either side of it.
| Code | MDM Level | Time (Total) | Typical Scenario | Medicare Rate* |
|---|---|---|---|---|
| 99202 | Straightforward | 15–29 min | Uncomplicated UTI, minor skin condition | ~$93 |
| 99203 | Low | 30–44 min | New stable chronic condition, prescription drug management | ~$140 |
| 99204 | Moderate | 45–59 min | New chronic illness with exacerbation, undiagnosed new problem | ~$209 |
| 99205 | High | 60–74 min | New problem with severe threat to life or bodily function | ~$266 |
*Approximate 2024 non-facility national averages. Confirm current rates via the CMS Physician Fee Schedule.
Common Billing Errors and How to Avoid Them
Even experienced billing teams make mistakes with E/M codes. These are the errors most commonly associated with 99202 specifically.
Billing 99202 for an established patient
As noted above, this is among the most frequent errors. If the patient visited the same provider, specialty, or group practice within three years, they are established. Use 99211–99215 instead. When in doubt, check the patient’s encounter history in the practice management system before the claim goes out.
Insufficient documentation to support the code level
Selecting 99202 but documenting only a brief, non-specific note is a common audit target. The documentation must substantiate the MDM or time used to support the code. If the visit was truly straightforward and brief, 99202 is appropriate — just make sure the note says so clearly.
Confusing “visit type” with “place of service”
99202 applies to office and other outpatient settings. It is not used for hospital inpatient admissions, emergency department visits, or skilled nursing facility encounters, each of which has its own code set. Ensure the place of service code on the claim (POS 11 for office, POS 22 for outpatient hospital, etc.) matches the clinical setting.
Failing to document time when using the time-based pathway
If a provider chooses time as the basis for code selection, total time spent on the date of service must be explicitly documented. A note that reads “the patient was seen and evaluated” does not capture time. Practices should update note templates to include a time documentation field.
Compliance Note
Routine upcoding — billing 99203 or 99204 for encounters that clinically qualify as 99202 — is a common trigger for RAC (Recovery Audit Contractor) and OIG reviews. Periodic internal coding audits, particularly for new patient codes, are considered a best practice under any compliance program.
Telehealth Billing for 99202
99202 can be used for telehealth visits when all regulatory requirements are met. During the COVID-19 public health emergency, the Centers for Medicare & Medicaid Services (CMS) dramatically expanded telehealth flexibilities. Several of those expansions were subsequently extended, though the regulatory landscape continues to evolve.
As of 2024, Medicare continues to cover 99202 for audio-video telehealth visits for eligible beneficiaries, subject to applicable originating site rules and geographic restrictions that were relaxed under pandemic-era waivers. Audio-only visits face more restrictive rules and are subject to specific documentation requirements to demonstrate why audio-video was not available or appropriate.
Commercial payers have their own telehealth coverage policies that may or may not mirror Medicare’s. Always verify individual plan requirements before billing 99202 for a telehealth encounter, including any modifier requirements (commonly modifier 95 for synchronous telehealth or GT for Medicare telehealth when applicable).
Best Practices for Accurate 99202 Billing
Whether you are a solo practitioner, a large group practice, or a hospital-employed physician, getting 99202 billing right comes down to a few repeatable habits.
First, train clinical staff on the distinction between new and established patients — this classification should be verified at scheduling, confirmed at check-in, and reviewed before coding. Second, ensure note templates prompt providers to document either total time or each of the three MDM elements. Templates that make it easy to capture this information at the point of care reduce post-visit documentation burden and improve accuracy.
Third, conduct periodic coding audits. Reviewing a random sample of 99202 claims quarterly — checking that documentation supports the code and that all patients are truly new — helps catch systematic errors before they become payer issues. Finally, invest in ongoing coder and provider education. The 2021 E/M changes represented the most significant revision in decades, and confusion about MDM elements, the two-of-three rule, and time calculation remains common even years after implementation.
Revenue Integrity Tip
Undercoding is as costly as overcoding, just differently. If your providers are consistently billing 99202 for visits that involve low-complexity MDM or 30+ minutes of total time, a coding audit may reveal significant lost revenue — revenue that is entirely appropriate to capture with 99203 or higher when documentation supports it.
Final Takeaways
CPT code 99202 is a foundational code for any outpatient practice that sees new patients. It represents straightforward clinical encounters — the kind that make up a meaningful share of primary care, urgent care, and many specialty new-patient volumes. Getting it right means understanding who qualifies as a new patient, selecting the correct billing pathway (MDM or time), and ensuring the clinical note clearly supports the level billed.
The 2021 E/M revisions simplified many aspects of E/M coding, but they also introduced new nuances around MDM elements and total-time calculation that require ongoing attention. Providers and billing teams who stay current on payer policies, document thoroughly, and audit regularly will find that 99202 — used correctly — is both a clean claim and a defensible one.
When in doubt, consult your compliance officer, a certified professional coder (CPC), or your payer’s provider relations team. The investment in getting it right upfront is always smaller than the cost of addressing a denial, an audit, or a recoupment later.