CPT® Code 99202

Quick Reference:

• What 99202 means: Office or other outpatient visit for the evaluation and management of a new patient, requiring a medically appropriate history and/or examination and straightforward medical decision making (MDM). Report 99202 when the clinical picture is a single self-limited or minor problem and the overall work is low-intensity.
• MDM level: Straightforward MDM typically reflects (1) one self-limited or minor problem, (2) minimal or no data reviewed/analyzed, and (3) minimal risk of morbidity from additional diagnostic testing or treatment.
• Time option (2026 practical): You may select 99202 by total time when the provider documents 15–29 minutes spent on the date of the encounter performing qualifying activities (evaluation, counseling, documentation, coordination, etc.).
• New patient restriction: “New patient” status is not subjective. Medicare contractors emphasize that a patient is new when they have not received a face-to-face E/M or other professional service from the same physician (or another physician of the same specialty in the same group) within the past 3 years.
• Common compliant use case: A first-time office/outpatient visit for a minor, uncomplicated concern (e.g., uncomplicated URI symptoms, mild dermatitis, medication question without changes) where the plan is simple and risk is minimal.
• Modifier 25 is not automatic: If a minor procedure or other separately reportable service occurs on the same date, modifier 25 may be appended to 99202 only when the E/M is significant and separately identifiable beyond the pre-/post-service work of the procedure.
• Global surgical periods (modifier 24): If an unrelated office/outpatient E/M is furnished during a postoperative global period, modifier 24 may be used when payer rules are met and documentation supports that the visit is unrelated to the procedure.
• Teaching settings (modifier GC): Medicare requires modifier GC on E/M services provided in part by a resident under the direction of a teaching physician when billing rules for teaching physician involvement are met.

CPT 99202 is among the most frequently under- or over-coded new patient visit levels because its correct use depends on two concepts that are often misunderstood in daily workflow:

1. the definition of new patient in group practice settings, and
2. what qualifies as straightforward medical decision making under modern office/outpatient E/M rules.

When 99202 is miscoded, the most common exposure is not subtle clinical nuance; it is simple mismatch between the documentation and the code-level claims signal.

Payers and auditors typically focus on three avoidable failure points:

• reporting 99202 when the patient is actually established under the 3-year rule,
• reporting 99202 when the note indicates low-to-moderate or higher complexity decision making (multiple problems, medication management, broader workup), or
• reporting modifier 25 without documentation that clearly separates the E/M work from the procedure work.

This guide provides a payer-realistic, documentation-first method for using 99202 accurately and defensibly in 2026.

flowchart TD
    A[New Patient Office/Outpatient Visit] --> B{Patient new under\n3-year rule?}
    B -->|No| C[Use established patient\ncodes 99211-99215]
    B -->|Yes| D{Select by MDM\nor Time?}
    D -->|MDM| E{Straightforward MDM?\n1 minor problem,\nminimal data,\nminimal risk}
    D -->|Time| F{15-29 minutes\ntotal time documented?}
    E -->|Yes| G[Report 99202]
    E -->|No| H[Consider 99203-99205]
    F -->|Yes| G
    F -->|No| I{Less than 15 min?}
    I -->|Yes| J[Review if E/M\nis warranted]
    I -->|No| H
    G --> K{Same-day procedure?}
    K -->|Yes| L{E/M significant and\nseparately identifiable?}
    K -->|No| M[Bill 99202]
    L -->|Yes| N[Bill 99202-25]
    L -->|No| O[Do not bill E/M\nseparately]

1. Definition and Service Scope

CPT 99202 is an office or other outpatient E/M service for a new patient. Under current office/outpatient E/M principles, code selection is driven by either medical decision making (MDM) or total time on the date of the encounter. History and exam remain clinically required when medically appropriate, but they are not the drivers of code level. Authoritative outpatient E/M guidance emphasizes that the note must reflect a medically appropriate history and/or examination and that the level is determined by MDM or time, not by counting historical or physical exam elements.

Operationally, 99202 is best viewed as the “true minor new patient visit.” The patient is new (per the 3-year rule), the presenting problem is uncomplicated, and the plan is simple. Examples include evaluation of a brief, self-limited complaint (e.g., mild upper respiratory symptoms), limited counseling, reassurance, or an uncomplicated diagnosis with conservative treatment. If the documentation reveals higher complexity elements—multiple problems, prescription drug management, extensive data review, imaging interpretation, or higher-risk differential diagnosis—then the visit likely belongs at a higher new patient level.

Practical boundary: In audit terms, the most defensible 99202 notes read “small.” They show a limited problem list, minimal data, and minimal risk. When the note reads “bigger” than the code (e.g., multiple chronic conditions assessed, medication changes, broader diagnostic evaluation), the 99202 claim becomes vulnerable even if the provider intended the visit to be simple.

2. MDM and Time Selection in 2026

2.1 Selecting 99202 by MDM

Selecting 99202 by MDM requires that the documentation supports straightforward decision making. In payer-facing E/M education materials, straightforward MDM generally corresponds to a limited clinical problem (often one minor problem), minimal data review, and minimal risk of morbidity from additional diagnostic testing or treatment. “Minimal risk” typically implies conservative management such as reassurance, over-the-counter medications, self-care instructions, or very limited diagnostic work with low-risk outcomes.

The key compliance principle is to let the record show the why behind the low intensity:

• Problem(s) addressed: Document that the complaint is self-limited or minor and that there are no red flags requiring escalation.
• Data: Document minimal data review (or no data) when that is true. If the provider reviews multiple external records, labs, or imaging, the “data” element may no longer be minimal.
• Risk: Document conservative treatment choices and the absence of high-risk decisions (no prescription management, no decision regarding hospitalization, no significant diagnostic workup with potential complications).

A frequent compliance pitfall is inadvertent inflation of complexity through templated documentation. For example, a template that lists multiple chronic diagnoses “reviewed,” even when not truly addressed, can make the visit appear more complex than intended. From a payer perspective, the medical record should reflect what was actually addressed and managed during the encounter.

2.2 Selecting 99202 by time

CPT 99202 may also be selected by total time when the provider documents 15–29 minutes spent on the date of the encounter performing qualifying work. Authoritative outpatient E/M guidance describes that time includes activities such as preparing to see the patient, obtaining and/or reviewing separately obtained history, performing a medically appropriate exam, counseling and educating, ordering medications/tests/procedures, documenting clinical information, interpreting results (when not separately reported), and coordinating care.

Two documentation behaviors improve defensibility when coding by time:

• State the total minutes clearly (e.g., “Total time today: 22 minutes.”).
• Include a brief time narrative showing what the time covered (e.g., counseling, documentation, coordination), especially when face-to-face time is not the majority of the work.

Coding by time is particularly useful when the clinical problem is minor but the visit includes extended counseling, coordination, or patient education that legitimately pushes the total work into the 15–29 minute window. However, coding by time does not remove the expectation that documentation supports a medically appropriate encounter; time should align with the work described in the note.

Time compliance note: If the record indicates a very limited clinical interaction (e.g., brief ROS, brief exam, minimal plan) but claims 29 minutes, that mismatch can trigger payer skepticism. Time statements should be plausible given the documented work.

3. Documentation Standards and Audit-Proofing

Although history and exam are no longer the basis for selecting the E/M level, documentation remains essential for demonstrating that the visit was medically appropriate and that the chosen code level is supported by either MDM or time. Outpatient E/M guidance emphasizes that clinicians should document a medically appropriate history and/or exam and that the note should clearly reflect the decision-making and/or time used to select the code.

3.1 Minimum documentation elements for a defensible 99202

• New patient status: Document that the patient is new to the practice (and ensure registration/PM system supports this under the 3-year rule).
• Chief complaint and brief HPI: A focused description of the minor problem and relevant context (duration, severity, key negatives/red flags).
• Medically appropriate exam: A focused exam relevant to the complaint (e.g., ENT and lung exam for URI symptoms).
• Assessment and plan: A simple diagnosis and conservative plan consistent with minimal risk and straightforward decision making.
• Data reviewed (if any): Document minimal data and keep it accurate (e.g., “Reviewed home COVID test result,” or “No external records reviewed.”).
• Time statement (when coding by time): Total minutes and a short narrative of qualifying activities.

3.2 Documenting “straightforward” MDM explicitly

In audits, the question is not whether the problem could be minor, but whether the clinician’s documentation demonstrates it was managed as a minor/self-limited problem with minimal risk. Practical documentation language includes:

• Low-risk plan language: “Supportive care,” “OTC as needed,” “Return precautions reviewed,” “No red flags on exam.”
• Minimal data language: “No labs or imaging indicated today,” “No external records reviewed,” when true.
• Risk containment language: “No prescription medication started,” “No escalation,” “No referrals required,” when true.

This does not mean “write for auditors.” It means write clearly enough that a payer reviewer can see why the complexity is straightforward rather than low or moderate.

3.3 Same-day procedure considerations (modifier 25 readiness)

When a same-day procedure is performed (e.g., immunization, minor skin procedure), the E/M service may be separately reportable only when it is significant and separately identifiable beyond the procedure’s inherent work. Authoritative E/M resources commonly emphasize that modifier 25 should not be appended reflexively; it must be supported by documentation distinguishing the E/M assessment and management from procedural work. A clear documentation strategy is to separate the note into distinct elements (e.g., “E/M assessment” and “Procedure note”) or clearly document two separate clinical purposes.

4. Medicare and “New Patient” Rules

Medicare contractor guidance explains that a patient is considered new if they have not received any professional service (including a face-to-face E/M or other professional service) from the physician or another physician of the same specialty in the same group practice within the prior 3 years. This definition is operationally critical because it determines whether any 9920x “new patient” code is allowed at all.

Two real-world scenarios cause frequent errors:

• Group practice crossover: A patient seen by a colleague of the same specialty in the same group within 3 years is established for the group even if the specific clinician has never met them. Medicare contractor guidance highlights the specialty/group concept explicitly.
• Non-office professional services count: A face-to-face professional service outside the office setting may affect new/established status depending on the circumstances. Practices should rely on careful records review and payer guidance rather than assumptions.

Best practice is operational, not philosophical: confirm new/established status at registration and during chart review, especially for patients referred within the same multispecialty group. If a payer later recategorizes the patient as established, the new patient E/M code can deny or trigger recoupment.

Compliance note: “New to me” is not the same as “new patient.” For billing, the payer definition controls. A claim can be correct clinically but still incorrect administratively if the patient fails the 3-year rule.

5. Modifier Usage (25, 24, GC)

5.1 Modifier 25 (significant, separately identifiable E/M)

Modifier 25 is appended to an E/M code when a significant, separately identifiable E/M service is performed by the same provider on the same day as another procedure or service. The E/M must be above and beyond the typical pre- and post-service work associated with the procedure. In practice, this means the visit must have its own clinical reason and its own documented assessment/plan that is distinct from the procedure work. Outpatient E/M guidance commonly highlights this documentation-driven approach to modifier 25.

For 99202 specifically, modifier 25 should be used sparingly because the base service is already “minimal.” If the clinical story includes a procedure plus a meaningful separate evaluation of a minor problem, 99202-25 can be appropriate. However, if the visit is solely for the procedure (e.g., vaccination-only visit without a separate problem evaluation), an E/M may not be supported.

5.2 Modifier 24 (unrelated E/M during a postoperative period)

Modifier 24 is used when an E/M service is furnished during a postoperative global period but is unrelated to the procedure that established the global period. Payer guidance emphasizes that the unrelated nature must be supported by documentation. A practical example is a patient in a global period who presents with an acute, unrelated problem (e.g., a respiratory infection) that requires evaluation and management distinct from postoperative care.

Documentation should clearly show:

• The unrelated complaint and its workup/management.
• No overlap with postoperative management of the prior procedure.

5.3 Modifier GC (resident involvement, Medicare teaching settings)

Medicare rules in teaching settings require specific attestation and involvement standards for teaching physicians when residents participate in care. Medicare contractor guidance on modifier GC indicates that GC is used to identify services that have been performed in part by a resident under the direction of a teaching physician when billing rules are satisfied. The compliance risk is not simply missing the GC modifier; it is missing documentation that supports teaching physician participation.

Teaching compliance note: GC is a billing signal. The medical record still must support teaching physician presence/participation per Medicare teaching physician requirements; otherwise the claim can be denied or recouped regardless of whether GC is appended.

6. Comparison Table: 99202–99205

7. Real-World Clinical Scenarios

Scenario 1: Minor acute illness (classic 99202)

Patient: 28-year-old, new patient, 3 days of mild cough and nasal congestion.

Work performed: Focused HPI, medically appropriate exam (lungs clear, no fever, no red flags), brief counseling on supportive care and return precautions.

Data: None (no labs/imaging).

Risk: Minimal (OTC recommendations only).

Code selection: 99202 by straightforward MDM or by time if total time documented as 15–29 minutes.

Documentation tip: Make the note clearly reflect why the problem is minor and why no diagnostic escalation is needed (e.g., “No dyspnea, normal lung exam, no fever; supportive care recommended.”).

Scenario 2: Minor rash, conservative plan

Patient: 34-year-old, new patient, mild pruritic dermatitis after new detergent exposure.

Work performed: Focused history, targeted skin exam, simple plan (avoid trigger, emollient/OTC topical, return if worsens).

Data: None.

Risk: Minimal.

Code selection: 99202 (straightforward MDM).

Documentation tip: Avoid documenting broad differential diagnoses unless clinically necessary; extensive differential language can appear like higher complexity decision-making.

Scenario 3: Counseling-focused new patient visit (99202 by time)

Patient: 40-year-old, new patient, visit focused on smoking cessation counseling.

Work performed: Counseling on risks, options, quit plan, and follow-up; minimal exam; no data review.

Time: Provider documents 25 minutes total time on date of encounter.

Code selection: 99202 by time (15–29 minutes) when documented appropriately.

Documentation tip: Include a clear total time statement and short narrative of tasks performed (counseling, coordination, documentation) to support time-based selection.

Scenario 4: Same-day immunization and minor complaint (99202-25 possible)

Patient: New patient presents for vaccine but also reports a separate minor complaint (e.g., mild seasonal allergic rhinitis symptoms).

Work performed: Separate evaluation of allergy symptoms (focused history/exam, OTC plan) plus immunization service.

Coding logic: 99202 may be reported with modifier 25 only if the record clearly distinguishes the E/M work from vaccine administration work and the E/M is significant and separately identifiable.

Documentation tip: Use clear separation (e.g., “E/M assessment and plan” vs “Immunization documentation”) so the record supports why an E/M was needed in addition to the vaccine service.

Scenario 5: Teaching clinic new patient visit (99202-GC)

Setting: Teaching clinic where a resident participates in the encounter.

Work performed: Resident performs initial evaluation; teaching physician participates per Medicare teaching rules and documents appropriate involvement/attestation.

Coding logic: When billing Medicare under teaching physician rules, append modifier GC as directed by Medicare contractor guidance for resident involvement.

Documentation tip: Ensure teaching physician documentation supports required participation; the modifier alone is not sufficient.

8. Common Errors and How to Prevent Denials

8.1 Error: Reporting 99202 when the patient is established

This is one of the highest-frequency denial/recoupment drivers. A patient may be “new to you” but still established to the group under Medicare’s 3-year, same-specialty rule. Prevention is operational: confirm prior encounters across the group and verify specialty matching. Medicare contractor education on new vs established status is the best anchor for staff training and front-end workflows.

8.2 Error: The note reads like higher complexity MDM

If documentation shows multiple problems actively assessed, medication management, or non-minimal data review, the visit may not support straightforward MDM. Prevention strategies include (1) ensuring the assessment/plan reflects what was actually managed, (2) avoiding unnecessary “problem list review” language that implies active management of multiple chronic conditions, and (3) aligning the documented risk with the plan (e.g., conservative vs prescription management). Outpatient E/M guidance is a practical reference for calibrating documentation to MDM or time.

8.3 Error: Time-based coding without a clear total time statement

When selecting by time, the record should explicitly state the total minutes and reflect qualifying activities on the date of service. Time-based coding is defensible when the time is documented clearly and is plausible given the described work.

8.4 Error: Modifier 25 appended reflexively

Modifier 25 is a common audit trigger because it can be used to bypass bundling logic when not supported. Prevention is documentation clarity: if a procedure is performed, ensure the E/M portion is truly separate and significant, with its own clinical purpose and management. If the visit is solely for the procedure, do not bill an E/M.

8.5 Error: Modifier 24 used without clear unrelated documentation

In global periods, payers expect that postoperative visits related to the surgery are included in the global package. Modifier 24 is appropriate only for unrelated problems. Payer guidance emphasizes the need for documentation demonstrating the lack of relationship to the procedure.