Office visit for a new patient
CPT® Code 99202 is used to report an office or other outpatient visit for the evaluation and management (E/M) of a new patient. This code applies when the total time spent on the encounter is 15 to 29 minutes, or when the medical decision making (MDM) is of straightforward complexity. It is the lowest-level new patient E/M code and typically reflects a simple visit for a minor or uncomplicated medical issue.
When to use CPT® Code 99202
This code is appropriate when:
- The patient is new to the practice and is being evaluated for a minor or uncomplicated health issue.
- The total time spent by the provider is between 15 and 29 minutes on the date of the encounter.
- The visit involves straightforward medical decision making, such as for common acute conditions or initial evaluation of stable chronic issues.
Examples may include:
- A first-time visit for a minor skin rash
- Evaluation of mild seasonal allergies
- Review of a single lab result with no significant concern
The provider may choose this code based on either total time spent or the level of medical decision making.
Medical decision making requirements
To bill based on medical decision making (MDM), the encounter must involve straightforward complexity, defined as:
- Number and complexity of problems addressed: One self-limited or minor problem, or a stable chronic condition.
- Amount and/or complexity of data reviewed: Minimal or none (e.g., review of a simple test or report).
- Risk of complications and/or morbidity or mortality: Minimal (e.g., OTC medication recommendations, basic treatment guidance).
Time requirements
When selecting the code based on total time, the provider must spend 15 to 29 minutes on the date of the encounter performing activities such as:
- Reviewing the patient’s history and records
- Conducting an examination
- Educating or counseling the patient or family
- Documenting clinical information in the EHR
- Ordering diagnostic tests or referrals
- Communicating with other healthcare professionals (if relevant)
Note: Time reflects total time spent by the provider on the date of the encounter, including both face-to-face and non-face-to-face activities related to the visit.
Key documentation tips
- Clearly document whether the code is selected based on time or MDM.
- If using time, include the total minutes spent and describe the related tasks performed.
- Support the level of service with clear, concise notes on the patient's concerns, the exam (if applicable), assessment, and plan.
- Specify that the patient is new to the practice, as this code is not applicable to established patients.
How OptiMantra supports accurate coding for CPT® 99202
OptiMantra offers intuitive, time-saving tools to help providers confidently document and bill for low-complexity visits like CPT 99202. Here's how it helps:
- Time tracking integration: Accurately logs provider time spent on each part of the patient encounter, helping to justify time-based coding.
- Structured EHR templates: Tailored for new patient visits and MDM documentation, ensuring that all necessary clinical details are captured.
- Real-time coding guidance: Recommends the correct CPT code based on time or MDM inputs, reducing coding errors and omissions.
- Seamless billing workflow: Connects clinical documentation to billing, reducing administrative overhead and speeding up claim processing.
- Compliance-ready records: Maintains a detailed audit trail with time stamps, structured data, and documentation fields to support payer reviews.
With OptiMantra, practices can confidently capture and code for low-complexity new patient visits, improve reimbursement accuracy, and maintain audit-ready documentation—without sacrificing valuable clinical time.
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