The CMS Comprehensive Error Rate Testing (CERT) program flags evaluation and management codes as the largest source of Medicare improper payments, year after year. CPT code 99202 is an evaluation and management code used for new patient office or other outpatient visits that require straightforward medical decision making or 15 to 29 minutes of total provider time on the date of the encounter.
That’s the textbook definition. Here’s the real problem.
Payer audit data from 2023 shows that roughly 23% of CPT code 99202 claims contained documentation deficiencies, coding mismatches, or patient status errors. For a mid-size practice billing 80 new patient visits per month, that error rate translates to about 18 rejected or underpaid claims every month. Over a full year, that’s tens of thousands in revenue your practice already earned but never collected.
This guide doesn’t stop at definitions. It maps payer-specific billing rules across Medicare, Medicaid, and commercial plans. It identifies the compliance traps that trigger audits and walks through denial appeal frameworks with actual sample language. You’ll also get a 12-point clean claim checklist built for the way real practices actually work, not how textbooks say they should.
One O Seven RCM is a revenue cycle management company that helps healthcare providers eliminate coding errors, recover denied revenue, and maintain payer compliance across every E/M encounter. We built this playbook from the same processes we use to protect our clients’ clean claim rate every day. If your practice handles its own medical billing services, the frameworks here will sharpen your accuracy. If you’re ready to hand the complexity off, we’re here for that too.
Table of Contents
- What Is CPT Code 99202?
- 99202 CPT Code Description
- Who Is a New Patient for CPT Code 99202? The 3-Year Rule and Group Practice Traps
- CPT Code 99202 Time Requirements: What Counts and Where Payers Disagree
- MDM Criteria for CPT Code 99202: How to Assess Straightforward Complexity
- Time-Based vs MDM-Based Coding for 99202: Which Method Survives a Payer Audit?
- 99202 Clean Claim Checklist: 12 Points to Clear Before Submission
- Who Can Bill CPT Code 99202? Provider Eligibility by Specialty and State Scope
- CPT Code 99202 Reimbursement Rates by Payer (2026)
- CPT Codes 99202 to 99205: New Patient Code Ladder with Specialty Application
- 99202 CPT Code RVU Breakdown and Contract Negotiation Leverage (2026)
- 99202 Modifier Requirements: Payer-Specific Rules for Modifier 25, Telehealth, and More
- G2211 with 99202: How to Stack Revenue on Qualifying Visits (2026)
- Can 99202 Be Used for Telehealth? State-Level Billing Rules for 2026
- ICD-10 Codes Paired with CPT Code 99202: Medical Necessity Crosswalk
- How to Bill 99202 by Specialty: Documentation Nuances Across 8 Practice Types
- How to Configure Your EHR for 99202 Compliance
- 99202 Denial Prevention and Recovery: Root Causes, Appeal Frameworks and Revenue Recovery
- 99202 Quarterly Self-Audit Scorecard: Measure, Score, and Improve Coding Accuracy
- Frequently Asked Questions About CPT Code 99202
What Is CPT Code 99202?
CPT code 99202 is an evaluation and management billing code used for office or other outpatient visits involving a new patient who requires straightforward medical decision making or 15 to 29 minutes of total provider time. It sits within the Current Procedural Terminology system maintained by the American Medical Association (AMA) and is recognized by the Centers for Medicare and Medicaid Services (CMS) for Medicare reimbursement.
The code belongs to the Office or Other Outpatient Services family (99202 through 99215) and is designated exclusively for new patients. What is CPT code 99202 in practical terms? It’s the lowest-complexity office visit code for someone your practice hasn’t seen before. You can find the full code specifications in the AAPC code database.
Here’s a quick snapshot of the CPT code 99202 definition and core requirements:
Code Snapshot
| Element | Specification | Compliance Note |
| CPT Code | 99202 | Verify code is active in current fee schedule before billing |
| Code Family | Office or Other Outpatient E/M (99202 to 99215) | Do not use for inpatient, observation, or ED encounters |
| Patient Status | New patient (3-year rule applies) | Confirm no professional services from same provider, specialty, or group in prior 3 years |
| MDM Level | Straightforward | 2 of 3 MDM elements must meet or exceed straightforward threshold |
| Time Range | 15 to 29 minutes total time on date of encounter | Only billing provider’s personal time counts |
| Medicare Rate (2026, Non-Facility) | Approximately $72 | Rate varies by GPCI; verify per locality |
| Place of Service | Office (POS 11) or Other Outpatient | Telehealth POS codes differ (POS 02 or POS 10) |
| Effective Since | January 1, 2021 (current descriptor) | 99201 was deleted on the same date |
Providers choose CPT code 99202 based on one of two pathways: the level of medical decision making (straightforward) or total time spent on the encounter date (15 to 29 minutes). The 2021 E/M guideline overhaul by the AMA and CMS established this dual-pathway system, replacing the old three-component framework that had been in place for decades.
This office visit CPT code for a new patient applies across multiple specialties, from primary care and dermatology to chiropractic and behavioral health. Each specialty handles documentation a little differently. We cover those nuances in the dedicated specialty billing matrix later in this guide.
99202 CPT Code Description
The official AMA CPT Professional Edition descriptor reads:
“Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 15 minutes must be met or exceeded.”
In practical terms, the 99202 CPT code description means the provider assesses the patient’s presenting concern using a clinically relevant history or examination and reaches a straightforward clinical conclusion. No complex workup. No extensive data review. No high-risk treatment decisions. The visit covers the lowest tier of clinical complexity for a patient the provider is seeing for the first time.
That’s the CPT code 99202 description stripped of the jargon. One self-limited problem, minimal data, minimal risk. If any of those elements tip higher, you’re looking at 99203 or above.
Is CPT Code 99202 Still Valid in 2026?
Yes. CPT code 99202 is an active, billable code in 2026. It wasn’t affected by the 2021 deletion of 99201, and no changes to its descriptor have been announced for future code cycles. CMS continues to recognize it across all Medicare Administrative Contractor regions.
If you’ve heard rumors about 99202 being phased out, they’re not accurate. The code is stable. What does change from year to year are the payment rates, policy rules around add-on codes like G2211, and payer-specific documentation expectations. Those are the moving parts you need to track.
99202 Change Timeline: 2019 to 2026
Most articles cover the 2021 changes in a paragraph. Here’s the full picture of every policy shift that’s affected how you bill and get paid for 99202.
| Year | Change | Impact on 99202 |
| Pre-2021 | Code selection required 3 key components: history, exam, MDM. Typical face-to-face time referenced. | Rigid documentation requirements; providers often defaulted to 99202 to minimize audit risk |
| January 1, 2021 | AMA/CMS overhaul: dual-pathway selection (time OR MDM). Key components replaced by “medically appropriate history and/or examination.” CPT 99201 deleted. | 99202 became the lowest-level new patient E/M code. Documentation burden reduced. Time-based billing became a legitimate primary pathway. |
| January 1, 2024 | G2211 add-on code became separately payable. | Providers could add approximately $16 to $17 per eligible 99202 encounter for longitudinal care relationships. |
| January 1, 2025 | CMS created Modifier 25 exception for G2211 alongside preventive services and vaccines. | Expanded same-day billing opportunities for 99202 + G2211 + preventive service combinations. |
| January 1, 2026 | Dual conversion factor finalized ($33.57 QP / $33.40 non-QP). Practice expense methodology shift (+4% non-facility, -7% facility indirect PE RVUs). | Office-based 99202 billing sees slight payment increase. Hospital-employed providers see reduction. |
The takeaway: 99202 itself hasn’t changed since 2021. Everything around it has. The payment rules, the add-on code opportunities, and the conversion factor structure all look different than they did two years ago. Staying current on these shifts is what separates practices that capture full reimbursement from those that leave money behind.
Who Is a New Patient for CPT Code 99202? The 3-Year Rule and Group Practice Traps
The CMS and AMA define a new patient as someone who hasn’t received any professional services from the same physician, or another physician of the same specialty and subspecialty within the same group practice, within the previous three years. Professional services means face-to-face encounters reported under a specific CPT code.
Phone calls, patient portal messages, prescription refill requests, and administrative contacts don’t count toward that threshold. The three-year period is measured from the date of the last face-to-face service, not the date of the last appointment or the date the patient was last active in the EHR system. That distinction catches many practices off guard.
Multi-Specialty Group Edge Cases That Trigger Denials
The new patient three-year rule is clear when one provider is involved. Multi-specialty group practices run into harder questions, and that’s exactly where denials start. Here are two scenarios that show where practices get it right and where they don’t.
Scenario A: Correctly Classified as New Patient
A patient saw a hand surgeon within an orthopedic group in February 2024. In April 2026, the same patient schedules with a sports medicine physician in the same group. Hand surgery and sports medicine are recognized as different subspecialties within orthopedics. The patient qualifies as new to the sports medicine provider.
Scenario B: Incorrectly Classified as New Patient—Denial Risk
A patient saw a family medicine provider within a primary care group in June 2025. In January 2026, that same patient sees a different family medicine provider in the same group. Both providers share the same specialty. The patient is established, not new. Billing the CPT code for new patient services here triggers an automatic denial on most payer systems.
Patient status misclassification is the number one reason payers deny 99202 claims. Practices must verify patient status through EHR records, prior claims history, and payer eligibility checks before assigning this code. Relying on patient self-reporting alone isn’t sufficient for audit defense.
CPT Code 99202 Time Requirements: What Counts and Where Payers Disagree
When selecting CPT code 99202 based on time, the provider must spend at least 15 minutes but less than 30 minutes of total time on the date of the encounter. If total time falls below 15 minutes, the visit doesn’t meet the 99202 time requirement. At 30 minutes, the provider should evaluate whether the encounter supports CPT code 99203 instead.
“Total time” under the AMA definition includes both face-to-face and non-face-to-face activities personally performed by the billing provider on the same calendar date. Clinical staff time never counts, regardless of how involved the nurse or medical assistant was during the visit.
Activities That Count Toward Total Time
- Reviewing patient records, test results, and imaging before or after the visit
- Performing a medically appropriate history and/or examination
- Counseling and educating the patient, family, or caregiver
- Ordering medications, tests, or procedures
- Documenting clinical information in the medical record
- Communicating with other healthcare professionals about the patient (when not separately billed)
- Independently interpreting results (when not separately billed)
Activities That Do Not Count
- Time spent by nurses, medical assistants, or intake staff
- Travel time to or from the encounter
- Time for services billed separately under their own CPT codes
- General administrative tasks such as scheduling and insurance verification
- General teaching not specific to the patient’s care
Payer-Specific Time Documentation Rules
Most payers follow AMA guidelines for time-based code selection, but documentation expectations aren’t identical across the board. The table below maps those differences and flags the specific triggers that lead to rejection.
| Payer | Time Documentation Accepted for Code Selection? | Specific Requirements | Common Rejection Triggers |
| Medicare (CMS) | Yes | Total time on date of encounter. No per-task breakdown required. | Vague entries such as “spent time with patient,” missing total minutes |
| Blue Cross Blue Shield | Yes (most plans) | Follows AMA guidelines. Some regional plans require start and stop time. | Inconsistency between documented time and service complexity |
| UnitedHealthcare | Yes | Follows AMA guidelines. Requires a statement of activities performed. | Time documented without corresponding clinical content in the note |
| Aetna | Yes | Follows AMA guidelines with additional emphasis on medical necessity linkage. | Time-based selection for visits with clearly minimal complexity |
| Cigna | Yes | Follows AMA guidelines. | Similar to Medicare |
| Medicaid (varies by state) | Varies | Some state Medicaid programs still prefer MDM-based documentation. Verify state-specific requirements. | Using time-based selection in states that default to MDM |
How to Document Time for Audit Protection
According to the AMA time documentation guidelines, providers aren’t required to document time per individual task. The note needs the total number of minutes and a description of what activities that time covered. That’s the standard.
Here’s what a compliant time-based note looks like for a dermatology encounter:
Compliant Documentation Example
“Total clinician time on date of service: 24 minutes. Activities included reviewing prior dermatology records from an outside provider, face-to-face evaluation and focused skin examination, counseling patient regarding topical treatment options, and clinical documentation.”
Compare that to: “Saw patient. Discussed concerns.” That entry provides zero audit defense. Vague time documentation is the most common reason payers downcode or deny time-based 99202 claims on audit review.
The clinical content in the note also has to match the time claimed. A note documenting 24 minutes needs enough substance to support 24 minutes of provider work. Payers reviewing time-based claims look at both numbers.
| CPT Code | Time Range | MDM Level | Medicare Non-Facility Rate (2026) | Revenue Difference vs 99202 |
| 99202 | 15 to 29 min | Straightforward | ~$72 | Baseline |
| 99203 | 30 to 44 min | Low | ~$107 | +$35 per visit |
| 99204 | 45 to 59 min | Moderate | ~$168 | +$96 per visit |
| 99205 | 60 to 74 min | High | ~$212 | +$140 per visit |
That revenue difference column matters more than practices realize. Undercoding by one level on 50 visits per month costs the practice over $1,700 in recoverable revenue. Overcoding by one level on the same volume creates an equal audit exposure.
MDM Criteria for CPT Code 99202: How to Assess Straightforward Complexity
When selecting CPT code 99202 based on medical decision making, the MDM must qualify as straightforward. The AMA CPT guidelines, reinforced by the CMS MLN Evaluation and Management Services Guide, define MDM through three elements. The provider must meet or exceed the straightforward threshold in at least two of three elements. That’s the “2 of 3” rule.
The Three MDM Elements at Straightforward Level
| MDM Element | What Meets Straightforward | What Exceeds Straightforward (Triggers 99203+) | Clinical Red Flag |
| Number and Complexity of Problems | One self-limited or minor problem (e.g., tension headache, contact dermatitis, insect bite) | Two or more self-limited problems, or one stable chronic illness | If the patient presents with a chronic condition, document stability explicitly or consider upcoding |
| Data Reviewed and Analyzed | Minimal or none (e.g., no labs ordered, no outside records reviewed) | Limited data: ordering and reviewing one basic diagnostic test | If you order any diagnostic test, including a rapid strep, the data element likely exceeds straightforward |
| Risk of Complications, Morbidity, or Mortality | Minimal risk (e.g., OTC medications, rest, topical treatment, activity modification) | Low risk: new prescription drug management | If you write a new prescription (not OTC), risk automatically tips to low and supports 99203 |
MDM Clinical Decision Flowchart
Use this three-step path before coding any new patient encounter.
Step 1: How many problems are you addressing today?
- One self-limited or minor problem → Straightforward for Element 1
- Two or more problems, or one chronic condition → Exceeds straightforward
Step 2: Are you ordering or reviewing any diagnostic data?
- No data needed → Straightforward for Element 2
- Ordering or reviewing even one basic diagnostic test → Exceeds straightforward
Step 3: What is the highest-risk treatment decision?
- OTC recommendation, rest, or topical treatment → Straightforward for Element 3
- New prescription, minor procedure, or referral for diagnostic imaging → Exceeds straightforward
Decision: If 2 of 3 elements meet straightforward, bill 99202. If 2 of 3 elements exceed straightforward, evaluate 99203 or higher.
Here’s how that plays out in practice. A new patient presents with a mild tension headache that started two days ago. No red flag symptoms: no sudden onset, no neurological deficits, no history of head trauma.
The provider performs a focused history and limited neurological screening of cranial nerves and pupil response, then recommends OTC acetaminophen and hydration. No imaging is ordered. No prescription is written.
MDM mapping: one self-limited problem, no data reviewed, and minimal risk from an OTC recommendation. All three elements meet the straightforward MDM threshold. This encounter qualifies under the CPT code 99202 requirements for straightforward medical decision making.
Change one detail and the code changes too. If that same patient has a history of migraines requiring a triptan prescription, the risk element exceeds straightforward because of new prescription management. At minimum, that’s 99203.
Time-Based vs MDM-Based Coding for 99202: Which Method Survives a Payer Audit?
CPT 99202 can be selected based on either total time (15 to 29 minutes) or straightforward medical decision making. It is not exclusively a timed code. Since the 2021 evaluation and management guideline overhaul, providers choose the documentation pathway that best reflects the work performed. Both are valid. But they don’t carry equal audit risk.
When Time-Based Selection Protects You
Time-based selection earns its place when the encounter involves significant non-face-to-face work that MDM wouldn’t capture. Outside record review before the visit, care coordination calls with referring providers, and pre-visit patient history documentation all count toward total time but contribute nothing to MDM scoring.
When the clinical complexity is genuinely straightforward but the provider invested real effort in preparation and documentation, time captures that work accurately. Document total minutes with an activity summary: “Total clinician time: 22 minutes. Reviewed outside records, conducted evaluation, counseled patient on treatment options, documented encounter.” That’s your auditable paper trail.
When MDM-Based Selection Is Safer
MDM is the safer choice when the visit was efficient and the clinical findings map cleanly to straightforward complexity. One self-limited problem, no data reviewed, minimal risk, OTC treatment: those elements create a direct, auditable link between the clinical content and the code. There’s no need to defend whether 15 minutes of provider time was “really necessary.”
Time inflation is a real audit trigger. Payers flag payer-specific time-based 99202 claims when documented minutes seem high relative to the clinical content in the note. MDM selection removes that exposure entirely.
Audit Survival Comparison
| Audit Scenario | Time-Based Outcome | MDM-Based Outcome | Recommended Method |
| Payer requests clinical justification for code level | Must show documented minutes plus activity description | Must show 2 of 3 MDM elements at straightforward level | Either (depends on documentation strength) |
| Payer questions whether visit complexity warranted 99202 | Time documentation accepted if activities align with clinical content | MDM elements directly demonstrate clinical complexity | MDM (stronger linkage to clinical content) |
| Visit involved extensive pre-visit record review with minimal face-to-face time | Time captures full effort; MDM alone would underrepresent work | MDM may not reflect non-face-to-face effort | Time (captures invisible work) |
| Visit was brief, focused encounter under 15 minutes | Cannot use time-based pathway below 15-minute threshold | MDM still supports 99202 if 2 of 3 elements meet straightforward | MDM (mandatory fallback when time threshold is not met) |
| Payer suspects systematic upcoding from 99211 or 99212 to 99202 | Must prove patient was genuinely new AND time exceeded 15 minutes | Must prove patient was genuinely new AND MDM was straightforward | Either, plus patient status verification |
Practice Recommendation: Establish a practice-wide default selection method and document accordingly. Consistency across providers reduces audit risk because it demonstrates a systematic compliance approach rather than opportunistic code selection.
99202 Clean Claim Checklist: 12 Points to Clear Before Submission
The difference between a claim that pays on first submission and one that sits in denial for 45 days often comes down to pre-submission verification. Practices with a structured clean claim checklist achieve clean claim rates above 95% on first-pass resolution. Practices without one hover around 80%, meaning one in five 99202 CPT code claims requires rework, appeal, or write-off.
The 12-point checklist below covers every element payers evaluate when adjudicating a 99202 claim. It goes beyond clinical documentation to include payer-specific claim-level fields that coders and billing staff must verify before hitting submit.
Pre-Submission Verification Checklist
| # | Checkpoint | Category | Pass Criteria |
| 1 | Patient status verified as NEW | Clinical | EHR and claims data confirm no professional services from same provider, specialty, or group within the prior three years |
| 2 | Code selection method documented (time or MDM) | Clinical | Provider note explicitly states which method was used |
| 3 | If time-based: total minutes recorded with activity summary | Clinical | Specific number of minutes plus brief description of activities performed |
| 4 | If MDM-based: all three elements addressed in the note | Clinical | Problems, data, and risk level documented. Two of three meet straightforward. |
| 5 | Assessment with ICD-10 diagnosis code | Clinical | Diagnosis is specific (avoid unspecified codes when specificity is available) and supports medical necessity |
| 6 | Treatment plan with follow-up instructions | Clinical | Documented plan directly relates to the assessed diagnosis |
| 7 | Provider attestation and signature | Clinical | Billing provider personally performed the service and signed the encounter |
| 8 | Correct Place of Service code | Claim-Level | POS 11 for office, POS 02 or 10 for telehealth. Do not use POS 22 (hospital outpatient) for office-based 99202 services. |
| 9 | Modifier accuracy | Claim-Level | Modifier 25 only if a separate procedure was performed the same day. Modifier 95 or 93 for telehealth. No modifier needed for standalone 99202. |
| 10 | No duplicate billing for same date of service | Claim-Level | Verify 99202 is not billed alongside another E/M code for the same patient on the same date without supporting documentation |
| 11 | Payer-specific time documentation requirements met | Payer Verification | Confirm payer accepts time-based selection. Some regional BCBS plans require start and stop time. |
| 12 | Prior authorization not required | Payer Verification | Most payers don’t require prior auth for office E/M visits, but some Medicaid MCOs and specialty referral situations may. Confirm before billing. |
Sample Clinical Note for a 99202 Visit
A complete sample note is more useful than a list of requirements. The contact dermatitis encounter below demonstrates how every CPT code 99202 requirements element works together in a single new patient visit.
Patient: [Name], DOB [Date] Date of Service: [Date] Visit Type: New Patient, Office Visit
Chief Complaint: Itchy, red rash on both forearms for five days.
History: Patient reports onset of a bilateral forearm rash approximately five days ago. Works as a laboratory technician. Rash appeared after handling a new chemical reagent at work without gloves. No fever. No spreading to other body areas. No history of eczema or psoriasis. No current medications. No known drug allergies.
Examination: Bilateral forearms display erythematous, mildly vesicular patches with clear demarcation at the wrist line. No secondary infection. No lymphadenopathy.
Assessment: Contact dermatitis, unspecified (ICD-10 L25.9). Likely occupational chemical irritant exposure.
Plan: Topical hydrocortisone 1% cream applied twice daily for seven days. Instructed patient to use protective gloves when handling reagents. Follow up in two weeks if rash does not resolve. Return sooner if worsening, spreading, or signs of infection develop.
MDM Statement: Straightforward. One self-limited problem (contact dermatitis), no data reviewed, minimal risk (OTC topical treatment).
Code Selection Basis: Medical decision making.
Total Provider Time: 19 minutes (documented for reference; code selected by MDM).
Four documentation failures that show up consistently in denied 99202 claims:
- Chief complaint documented as a bare symptom without context (“rash” instead of “itchy red rash on forearms for five days after chemical exposure”)
- Missing code selection basis statement, leaving the payer unable to determine whether the code was selected by time or MDM
- Assessment without an ICD-10 code (some EHR systems don’t auto-populate; verify manually before submission)
- Follow-up plan that is vague or absent (“return as needed” without a specific timeline or red flag instructions)
Building a 12-point verification process into every E/M claim takes resources most practices don’t have in-house. One O Seven RCM provides medical billing services at 2.99% of collections with built-in claim scrubbing, coding accuracy review, and pre-submission compliance checks. Every 99202 claim goes through our quality assurance process before it reaches the payer.
Who Can Bill CPT Code 99202? Provider Eligibility by Specialty and State Scope
CPT code 99202 can be billed by physicians (MD and DO), nurse practitioners (NP), and physician assistants (PA) who are credentialed with the payer and acting within their scope of practice. Some payers also accept clinical psychologists and licensed clinical social workers for E/M codes, subject to state-specific scope rules.
Provider Eligibility Table
| Provider Type | Can Bill 99202? | Billing Rate | Key Restriction |
| Physician (MD/DO) | Yes | 100% of fee schedule | None |
| Nurse Practitioner (NP) | Yes | Medicare: 85% of physician rate. Commercial: varies by contract. | Must be credentialed with each payer individually. Some states require collaborative agreement. |
| Physician Assistant (PA) | Yes | Medicare: 85% of physician rate. Commercial: varies by contract. | Must be credentialed. Some states require supervising physician documentation. |
| Clinical Psychologist | Varies | Varies by payer and state | Limited to E/M within behavioral health scope. Not all payers accept. |
| Licensed Clinical Social Worker | Varies | Varies by payer and state | Very limited E/M billing authority. Most commercial payers don’t accept. |
| Registered Nurse | No | Not applicable | Cannot independently bill E/M codes |
| Medical Assistant | No | Not applicable | Cannot bill or independently document E/M services |
State Scope-of-Practice Variation for NPPs
NP and PA billing authority for procedure code 99202 varies significantly by state. In full practice authority states, NPs bill independently without physician oversight. In reduced or restricted practice states, a collaborative agreement or direct supervision requirement may be in place, affecting both credentialing setup and payer-specific enrollment.
Full practice authority (NPs bill independently): AZ, CO, CT, HI, ID, IA, ME, MD, MN, MT, NE, NV, NH, NM, ND, OR, RI, SD, VT, WA, WY, and others (27 states plus DC).
Reduced practice authority (collaborative agreement required): AL, AR, DE, IL, IN, KY, LA, MS, OH, WI, and others.
Restricted practice authority (direct supervision required): CA, FL, GA, MI, MO, NC, SC, TX, VA, and others.
This landscape changes frequently. Providers should verify current regulations with their state licensing board before billing.
Incident-To Billing and 99202
Incident-to billing applies only to established patients. The 99202 CPT code is a new patient code and can’t be billed under incident-to arrangements. That’s one of the most common misunderstandings in multi-provider practices, and it leads to claims that pass internal review but fail at payer adjudication.
Providers who aren’t enrolled and credentialed with a payer can’t submit claims under their own NPI. Credentialing timelines run 60 to 120 days depending on the payer. Practices need to start the enrollment process well before a new provider begins seeing patients.
One O Seven RCM offers credentialing and contracting services at $99 per payer with an average turnaround that gets providers billing weeks faster than the industry average.
CPT Code 99202 Reimbursement Rates by Payer (2026)
The 2026 Medicare national non-facility reimbursement rate for CPT code 99202 is approximately $72 under the CMS Physician Fee Schedule. The facility rate is approximately $46. But 99202 CPT code reimbursement varies significantly depending on the payer, geographic locality, provider type, and contract terms. Knowing the 99202 CPT code cost across payers is essential for accurate revenue forecasting and contract negotiation.
Medicare Reimbursement and the Dual Conversion Factor
CMS calculates Medicare payments using the RVU formula: Payment = [(Work RVU x Work GPCI) + (PE RVU x PE GPCI) + (MP RVU x MP GPCI)] x Conversion Factor. The 2026 CMS Physician Fee Schedule Final Rule finalized two separate conversion factors under MACRA: $33.57 for qualifying APM participants and $33.40 for non-QP physicians.
| Setting | 2026 Rate | Notes |
| Non-Facility (Office) | ~$72 | National average. Ranges $63 to $88 by locality. |
| Facility (Hospital Outpatient) | ~$46 | Hospital absorbs practice expense; lower PE RVU applied. |
| Limiting Charge (Non-Participating) | ~$83 | Maximum allowed charge for non-participating Medicare providers. |
Medicaid Reimbursement Variation by State
Medicaid 99202 CPT code reimbursement varies dramatically by state, ranging from approximately $35 in the lowest-paying states to approximately $75 in the highest-paying states. The percentage-of-Medicare column below helps practices benchmark Medicaid income against their Medicare baseline.
| State | Estimated Medicaid Rate for 99202 | % of Medicare |
| New York | ~$65 to $70 | ~90% |
| California | ~$50 to $55 | ~70% |
| Texas | ~$45 to $50 | ~65% |
| Florida | ~$40 to $45 | ~58% |
| Mississippi | ~$35 to $40 | ~50% |
Medicaid rates are set by individual state fee schedules and change annually. Verify current rates through your state Medicaid agency or managed care organization.
Commercial Payer Rate Comparison
Commercial rates for CPT 99202 consistently exceed Medicare, but the gap depends on contract terms and regional market conditions. The negotiation leverage column below gives practices a starting point for rate discussions.
| Payer | Average Rate (2026) | % Above Medicare | Negotiation Leverage |
| Cigna | ~$109 | +51% | Historically highest commercial E/M rates. Use as the benchmark in negotiations with other payers. |
| Blue Cross Blue Shield | ~$83 | +15% | Rates vary significantly by regional plan. Request a rate schedule comparison across BCBS entities. |
| UnitedHealthcare | ~$82 | +14% | Largest commercial payer. Contract terms affect rate more than the base fee schedule. |
| Aetna | ~$81 | +13% | Competitive with UHC. Bundle E/M rates with procedure rates during negotiation. |
| Medicare | ~$72 | Baseline | Federal fee schedule. Not negotiable. |
| Medicaid | ~$35 to $70 | -3% to -51% | State-dependent. Often not negotiable, but MCO contracts may offer better rates. |
| Payer | Average Rate (2026) | % Above Medicare | Negotiation Leverage |
| Cigna | ~$109 | +51% | Historically highest commercial E/M rates. Use as the benchmark in negotiations with other payers. |
| Blue Cross Blue Shield | ~$83 | +15% | Rates vary significantly by regional plan. Request a rate schedule comparison across BCBS entities. |
| UnitedHealthcare | ~$82 | +14% | Largest commercial payer. Contract terms affect rate more than the base fee schedule. |
| Aetna | ~$81 | +13% | Competitive with UHC. Bundle E/M rates with procedure rates during negotiation. |
| Medicare | ~$72 | Baseline | Federal fee schedule. Not negotiable. |
| Medicaid | ~$35 to $70 | -3% to -51% | State-dependent. Often not negotiable, but MCO contracts may offer better rates. |
2026 CMS Policy Changes Affecting 99202 Payment
- E/M codes are exempt from the -2.5% efficiency adjustment. CMS applied this reduction to work RVUs for nearly all non-time-based services, but E/M codes including 99202 are classified as time-based and excluded. Practices with high E/M volume are less affected than procedure-heavy specialties.
- Practice expense methodology favors office-based billing. Indirect PE RVUs for non-facility settings increased by approximately 4%, while facility settings decreased by approximately 7%. Practices billing 99202 in an office setting see a slight reimbursement increase. Hospital-employed providers billing under a facility arrangement see a reduction.
- Dual conversion factor verification is now mandatory. Practices must confirm whether their billing entity qualifies as an APM participant ($33.57 conversion factor) or non-QP ($33.40 conversion factor). Using the wrong conversion factor in revenue projections creates a 0.5% forecasting error across all E/M claims, which compounds over thousands of annual encounters.
Capturing full reimbursement for every E/M code requires more than accurate coding. It demands clean claim submission, proactive denial management, and strategic AR follow-up. One O Seven RCM’s revenue cycle management services and medical billing at 2.99% of collections help practices capture every dollar earned across Medicare, Medicaid, and commercial payers.
CPT Codes 99202 to 99205: New Patient Code Ladder with Specialty Application
CPT 99202 is the entry-level code in the new patient office visit E/M range, which runs from 99202-99205. Choosing the correct code depends on either total provider time on the date of the encounter or the level of medical decision making documented. Knowing where the 99202-99205 range fits helps prevent two expensive mistakes: undercoding visits that support a higher level and overcoding visits that do not.
Full Code Range Comparison
| CPT Code | MDM Level | Time Range | Medicare Non-Facility (2026) | Revenue Loss If Undercoded to 99202 |
| 99202 | Straightforward | 15-29 min | ~$72 | Baseline |
| 99203 | Low | 30-44 min | ~$107 | -$35 per visit |
| 99204 | Moderate | 45-59 min | ~$168 | -$96 per visit |
| 99205 | High | 60-74 min | ~$212 | -$140 per visit |
CPT code 99201 was deleted effective January 1, 2021. The reason was redundancy: 99201 and CPT 99202 both represented straightforward MDM, so the lower code was removed from the family.
If total time is under 15 minutes and the encounter does not support straightforward MDM, the service may not be separately reportable as an office visit CPT code new patient service. If a visit exceeds 74 minutes, report 99205 plus prolonged services add-on code 99417 for each additional 15-minute increment. For higher-level coding guidance, see CPT code 99204 and CPT code 99205.
Which Specialties Bill Which Codes Most Often?
| Specialty | Most Common New Patient Code | Why |
| Primary Care / Family Medicine | 99203 | Most new patients present with 1 to 2 active problems requiring limited workup |
| Dermatology | 99202-99203 | Skin evaluations are often focused, with low-complexity assessment |
| Chiropractic | 99202-99203 | Initial musculoskeletal evaluations commonly fall in straightforward to low MDM |
| Mental Health / Psychiatry | 99204-99205 | Initial psychiatric evaluations often involve extensive history and higher-risk medication decisions |
| Orthopedics | 99203-99204 | Imaging review and possible surgical planning increase complexity |
| Cardiology | 99204-99205 | New patients often present with multiple chronic conditions and diagnostic workups |
| ENT / Otolaryngology | 99202-99203 | Focused evaluations for common complaints often remain lower complexity |
| OB/GYN | 99203-99204 | Initial reproductive health assessments frequently support low to moderate complexity |
If your practice bills the CPT code for new patient visits as 99202 for most new encounters, run an internal audit. Heavy reliance on the 99202 CPT code across all specialties is a payer red flag and may point to systematic undercoding.
99202 CPT Code RVU Breakdown and Contract Negotiation Leverage (2026)
The 99202 CPT code RVU structure drives Medicare reimbursement and serves as the baseline for commercial contract analysis. Understanding each relative value unit component helps practice leaders forecast revenue, compare fee schedules, and identify underpayment during contract review. The 99202 CPT code RVU profile is simple, but it has direct implications for payer negotiations.
RVU Component Table
| RVU Component | Non-Facility Value | Facility Value | What It Represents |
| Work RVU (wRVU) | 0.93 | 0.93 | Provider time, skill, effort, and clinical judgment |
| Practice Expense RVU (PE RVU) | 0.85 | 0.38 | Overhead such as staff, supplies, equipment, and rent |
| Malpractice RVU (MP RVU) | 0.05 | 0.05 | Professional liability insurance allocation |
| Total RVU | 1.83 | 1.36 | Sum of all components |
The biggest spread is in practice expense. Non-facility PE RVU is 0.85, while facility PE RVU is 0.38 because the hospital absorbs overhead. That difference helps explain the payment gap of roughly $26 between office and facility settings.
Medicare Payment Calculation Walkthrough
Payment formula:
Payment = [(wRVU x Work GPCI) + (PE RVU x PE GPCI) + (MP RVU x MP GPCI)] x conversion factor
Using national average GPCI values of 1.0 and the non-QP conversion factor of $33.40:
(0.93 + 0.85 + 0.05) x $33.40 = $61.12
That is the unadjusted baseline before geographic changes. In higher-cost areas such as Manhattan, San Francisco, and Boston, GPCI adjustments can bring payment into the $72 to $88 range.
Using RVU Data in Commercial Payer Negotiations
- Benchmark every payer against Medicare. If a payer reimburses 99202 at $75, that is about 104% of Medicare and likely under market for office E/M.
- Lead with high-volume E/M codes. A 5% increase across 99202-99215 usually outperforms a larger increase on low-volume procedures.
- Use the Cigna benchmark. If one payer sits at 115% of Medicare while stronger contracts approach 140% to 150%, you have a concrete negotiation anchor for fee schedule review.
99202 Modifier Requirements: Payer-Specific Rules for Modifier 25, Telehealth, and More
The most commonly used modifier with CPT code 99202 is Modifier 25, which indicates a significant, separately identifiable E/M service performed on the same day as a procedure. For telehealth encounters, Modifier 95 for synchronous audio-video or Modifier 93 for audio-only may apply. Some payers still use GT. Modifier rules are not universal, and that is where many denials start.
Modifier 25 with CPT Code 99202
CPT code 99202 modifier 25 is one of the most audited combinations in E/M coding. AMA guidance states that different diagnoses are not required to bill both an E/M service and a same-day procedure. What matters is whether the E/M work is significant and separately identifiable beyond the usual work included in the procedure.
The note must stand on its own with a distinct chief complaint, relevant history, assessment, and plan. Procedure-only documentation, cloned notes, or templated text that mirrors the procedure note creates denial risk. For reference, see the AMA Modifier 25 reporting guidance.
Telehealth Modifiers (95, 93, GT)
For 99202 CPT code telehealth billing, CMS generally prefers Modifier 95 for real-time audio-video telehealth. Modifier 93 applies to qualifying audio-only encounters. Some commercial plans and state Medicaid programs still require GT. Using the wrong modifier for procedure code 99202 often causes automatic front-end rejection in medical billing systems.
Payer-Specific Modifier Matrix
| Modifier | Medicare (CMS) | Blue Cross Blue Shield | UnitedHealthcare | Aetna | Cigna | Medicaid (General) |
| 25 | Accepted with supporting documentation | Accepted, but some regional plans want separate diagnoses | Accepted with increased scrutiny | Accepted | Accepted | Varies by state and MCO |
| 95 | Preferred for telehealth | Accepted by most plans; some regional plans use GT | Accepted | Accepted | Accepted | Varies |
| 93 | Accepted for qualifying audio-only services | Inconsistent by plan | Limited acceptance | Limited acceptance | Limited acceptance | Varies widely |
| GT | Still accepted but largely legacy | Required by some regional plans | Usually not required if 95 used | Not required | Not required | Some states still require it |
| 57 | Accepted when decision for major surgery is made | Standard | Standard | Standard | Standard | Standard |
| GC | Required in teaching settings | Follows CMS approach | Follows CMS approach | Follows CMS approach | Follows CMS approach | Follows CMS approach |
The most dangerous error is not picking the wrong modifier. It is assuming all payers follow the same rule set. A modifier combination that passes Medicare edits may still fail a commercial payer or state Medicaid plan. Build payer-specific logic into claim scrubbing and HIPAA-compliant edit workflows.
G2211 with 99202: How to Stack Revenue on Qualifying Visits (2026)
One of the most underused revenue opportunities tied to the 99202 CPT code is G2211. This Medicare add-on code pays roughly $16 to $17 extra per eligible visit when the encounter reflects the inherent complexity of an ongoing clinician-patient relationship. It can attach to base E/M codes 99202 through 99215 and, beginning January 1, 2026, also applies to home visit codes 99341 through 99350.
What Is G2211 and Who Can Bill It?
G2211 recognizes visits in which the clinician serves as the focal point for ongoing care coordination or assumes responsibility for managing a serious or complex condition over time. It is not specialty restricted. Any qualifying clinician may report G2211 when documentation supports a longitudinal care relationship.
At roughly $17 per visit, G2211 can add up quickly. A practice billing 200 eligible E/M visits per month could generate about $40,800 in additional annual revenue.
When G2211 Qualifies Alongside 99202
G2211 may be reported with 99202 when the new patient visit establishes care that is expected to continue. Example: a patient presents for initial evaluation of newly diagnosed hypertension. The provider begins management, sets follow-up, and documents intent to provide ongoing care. That supports 99202 plus G2211.
It does not qualify for one-time consultations, second opinions, or single-issue visits where the provider does not assume ongoing responsibility.
Modifier 25 Exception Timeline (2024-2026)
| Year | Rule | Practical Impact |
| 2024 | CMS blocked G2211 payment when the E/M code carried Modifier 25 | No stacking on same-day E/M plus procedure claims |
| 2025 | CMS allowed an exception for AWV, vaccine administration, or Medicare Part B preventive services | Expanded same-day billing opportunities |
| 2026 | Exception continues, and G2211 expands to home visit codes 99341-99350 | Broader stacking potential across qualifying visits |
Practices that are not billing G2211 on eligible encounters are leaving revenue behind. Review the last 90 days of claims and add G2211 eligibility checks to your submission workflow.
Can 99202 Be Used for Telehealth? State-Level Billing Rules for 2026
Yes. CMS and most commercial payers allow CPT 99202 for qualifying telehealth visits in 2026. The same time and MDM requirements apply as they do for in-person services. But telehealth billing rules vary by state, payer, and modality, especially for audio-only encounters. Billing without checking those rules creates real denial risk.
| Element | Requirement |
| Modifier (Audio + Video) | 95 under CMS, or GT for some plans |
| Modifier (Audio-Only) | 93 when audio-only is allowed |
| Place of Service | POS 02 or POS 10 |
| Technology | Real-time interactive technology using a HIPAA-compliant platform |
| Consent | Document patient consent; some states require written consent |
| Time Requirements | Same as in-person, 15-29 minutes for CPT 99202 when time is used |
| Documentation | Note that visit was telemedicine and identify platform used |
State-Level Telehealth Rules
| State | Audio-Video E/M Allowed | Audio-Only E/M Allowed | Parity Law | Originating Site Restrictions | Key Notes |
| California | Yes | Yes, limited | Yes through 2026 | None | Verify Medi-Cal MCO rules |
| Texas | Yes | Yes, limited | Yes | None | Broad telehealth access |
| New York | Yes | Yes | Yes through 2025, verify 2026 | None | Check renewal status |
| Florida | Yes | Yes, limited | No statewide parity | Varies by payer | Commercial rates may differ |
| Pennsylvania | Yes | Yes | Yes | None | Broad parity protections |
| Illinois | Yes | Yes | Yes | None | Audio-only parity recognized |
| Ohio | Yes | Limited | Partial | Some Medicaid MCO limits | Verify plan rules |
| Georgia | Yes | Limited | No statewide parity | Varies | Commercial rules dominate |
| Michigan | Yes | Yes | Yes | None | Strong parity framework |
| North Carolina | Yes | Limited | No comprehensive parity | Some payer restrictions | Verify payer-specific policies |
Telehealth laws change often. The table above reflects general policy direction as of early 2026, but providers should verify current requirements with their state medical board, Medicaid agency, and payer contracts before submitting 99202 CPT code telehealth claims.
ICD-10 Codes Paired with CPT Code 99202: Medical Necessity Crosswalk
Every CPT code must be paired with an appropriate ICD-10-CM diagnosis code to demonstrate medical necessity. Claims submitted without a valid diagnosis or with a code that doesn’t support the level of service billed will be denied. Below are ICD-10 codes frequently paired with 99202, organized by clinical category and flagged with payer-specific medical necessity notes.
| ICD-10 Code | Description | Common Specialty Context | Medical Necessity Notes |
| G44.209 | Tension-type headache, unspecified | Primary Care, Neurology | Well-supported for straightforward MDM if no imaging ordered |
| L25.9 | Contact dermatitis, unspecified | Dermatology, Occupational Medicine | Specify irritant versus allergic when documentation supports it |
| M54.5 | Low back pain | Chiropractic, Orthopedics, Primary Care | High-volume pairing. Some payers flag if used repeatedly without progression notes. |
| F41.9 | Anxiety disorder, unspecified | Mental Health, Primary Care | Acceptable for initial screening visit. Specify GAD (F41.1) if diagnosed. |
| J30.1 | Allergic rhinitis due to pollen | Primary Care, Allergy/Immunology | Strongly supported for straightforward seasonal complaint |
| L70.0 | Acne vulgaris | Dermatology, Pediatrics | Common for adolescent new patient visits |
| H61.20 | Impacted cerumen, unspecified ear | ENT, Primary Care | If cerumen removal performed same-day, use Modifier 25 on 99202 |
| Z30.09 | Encounter for other contraceptive management | OB/GYN, Primary Care | Counseling-only visit. Ensure time documentation supports 15+ minutes. |
| R51.9 | Headache, unspecified | Primary Care | Use only when specificity isn’t clinically available at the encounter |
| N39.0 | Urinary tract infection, site not specified | Primary Care, Urology | If urine culture ordered, MDM may tip to low complexity (99203) |
Select the most specific ICD-10 code your documentation supports. Unspecified codes ending in .9 should only be used when further specificity isn’t available at the time of the encounter. Multiple payers have implemented automated edits that flag unspecified codes for manual review.
How to Bill 99202 by Specialty: Documentation Nuances Across 8 Practice Types
The 99202 CPT code description is the same across specialties, but the chart note never looks the same from one practice to another. A straightforward evaluation and management visit in dermatology doesn’t read like one in chiropractic or OB/GYN. That’s where documentation mistakes start.
Primary Care / Family Medicine
A typical 99202 visit here is a new patient with a mild acute issue, such as sore throat, seasonal allergies, or a simple rash. Document the presenting problem clearly and tie it to one self-limited diagnosis. A common mistake is mixing a problem visit with a same-day preventive service without separating the note or using Modifier 25 when needed.
Dermatology
Most 99202 dermatology visits involve one focused concern, such as acne, eczema, or a benign-appearing mole. Document lesion location, size, appearance, and why no biopsy was indicated. What usually causes trouble is billing 99202 on the same day as a biopsy without proving the E/M work was separate from the procedure.
Chiropractic
A common scenario is a new patient with acute low back pain or cervical strain. The note should include spinal assessment, range of motion, and manual muscle findings. The issue is separation. If chiropractic manipulative treatment is billed the same day, the E/M documentation must stand on its own and not get buried inside the CMT note.
Mental Health / Behavioral Health
Here, 99202 often fits an initial screening visit for mild anxiety or adjustment symptoms. Psychiatric history, symptom severity, and a basic treatment plan should all be present. Screening tools such as PHQ-9 or GAD-7 help. A common mistake is using 99202 for psychotherapy visits or for encounters involving medication decisions that push MDM above straightforward.
Orthopedics
A straightforward orthopedic 99202 visit usually involves a minor musculoskeletal complaint, such as mild knee pain or ankle sprain, without imaging. Document range of motion, stability, and strength. This is where providers slip: once an X-ray is ordered or reviewed, the data element often moves beyond minimal and may support 99203 instead.
ENT / Otolaryngology
Simple ear complaints often fit 99202, especially cerumen impaction or mild otitis externa. Detailed otoscopic findings matter here. Document what was seen and why treatment was medically appropriate. A frequent error is billing 99202 with same-day cerumen removal and forgetting that separate E/M documentation, and often Modifier 25, is required.
Pediatrics
In pediatrics, 99202 often shows up for acne, a focused follow-up concern after a sports physical, or a minor new complaint. Age-appropriate history and developmental context should be part of the note. The common mistake is using 99202 when the visit is really preventive. In that case, preventive medicine codes usually fit better.
OB/GYN
Common 99202 scenarios include contraception counseling or initial evaluation of menstrual irregularity. Document reproductive history, current medications, and the counseling provided. What usually creates denials is poor separation between a problem-oriented E/M service and a routine gynecological exam. If both happen on the same day, the documentation has to make that distinction clear.
How to Configure Your EHR for 99202 Compliance
Most 99202 mistakes aren’t knowledge problems. They’re template problems. If the EHR doesn’t prompt the provider for the right details, gaps show up in the note, the claim goes out anyway, and the denial lands in billing two weeks later. A better template fixes a lot of that before it starts.
These recommendations work across major systems, including Epic, athenahealth, eClinicalWorks, Kareo, and DrChrono. The exact screens differ, but the workflow logic is the same.
MDM Prompt Template
Build these three fields directly into the encounter template:
Problems Addressed: “List each problem addressed during this encounter. Classify as self-limited, acute uncomplicated, chronic stable, chronic with exacerbation, or new problem requiring workup.”
Data Reviewed: “List tests, records, or imaging reviewed or ordered. If none, state: No external data reviewed or ordered.”
Risk Assessment: “Describe the highest-risk management decision: OTC treatment only, prescription drug management, minor procedure, elective major surgery, or emergency major surgery.”
That three-part structure forces the provider to document all MDM elements. It also improves the clean claim rate because coders aren’t left guessing what level the note supports.
Time Tracking Configuration
Set the time workflow to do four things:
- Auto-start when the encounter opens
- Show running time during documentation
- Auto-populate a total time field at close
- Add a linked field for activities performed
New Patient Verification Workflow
Use a simple three-step intake check before the provider assigns a code.
Step one: check EHR history for prior visits with the same provider or same-specialty group.
Step two: review claims history, if your system supports it, for billed services in the past three years.
Step three: use patient self-report only as a backup. If the flag is green, proceed. If it’s yellow or red, billing reviews it before final code selection. That’s how you keep the CPT code 99202 description aligned with the actual patient status.
99202 Denial Prevention and Recovery: Root Causes, Appeal Frameworks and Revenue Recovery
99202 looks simple on paper. In real billing, it isn’t. E/M services continue to show up as a major source of improper payments in Medicare review work, including the CMS CERT program. For 99202, the usual problems are documentation gaps, patient status mistakes, and coding mismatches. Each denial costs more than the fee itself. By the time staff rework, appeal, and follow up, the overhead often lands in the $25 to $35 range per claim.
Top 7 Denial Reasons for 99202 Claims
| # | Denial Reason | Root Cause | Prevention | If Already Denied |
| 1 | Patient status error | Three-year rule not verified | Add intake verification before coding | Appeal with records showing the three-year gap |
| 2 | Insufficient time documentation | Missing total minutes or vague entry | Use EHR timer and activity summary | Add provider attestation and resubmit if supported |
| 3 | MDM under-documented | One or more MDM elements missing | Use structured MDM prompts in the note | Request provider addendum and resubmit |
| 4 | Same-day preventive overlap | 99202 billed with preventive service without separate E/M support | Train staff on same-day billing and Modifier 25 use | Appeal with distinct complaint, assessment, and plan |
| 5 | Staff time counted | Nursing or MA time included in provider total time | Educate clinical staff on time rules | Correct time and reassess code level |
| 6 | Wrong place of service | POS does not match actual setting | Add POS check before submission | Correct claim and resubmit |
| 7 | Habitual undercoding | Providers default to 99202 regardless of complexity | Perform quarterly chart audits | Recode within timely filing if documentation supports it |
Denial Appeal Framework with Sample Language
When a 99202 denial comes in, don’t send a generic reconsideration. Match the appeal to the payer’s reason code.
Use this framework:
We are writing to appeal the denial of CPT code 99202 for Date of Service [DATE] for patient [NAME], Member ID [ID], Claim Number [CLAIM#]. Denial reason: [REASON CODE/DESCRIPTION].
The enclosed documentation shows that [PROVIDER NAME] performed a medically appropriate evaluation and management service for a new patient presenting with [CHIEF COMPLAINT]. The medical decision making was straightforward, involving [NUMBER] self-limited problem(s), [DATA REVIEWED OR NONE], and [RISK LEVEL] risk.
[If patient status denial:] Attached records confirm no professional services were rendered by this provider, or any same-specialty provider in our group, during the three-year period before the date of service.
[If time denial:] Provider attestation confirms total clinician time of [MINUTES] minutes on the date of service, including [ACTIVITIES].
[If Modifier 25 denial:] The enclosed note documents a significant, separately identifiable E/M service with its own chief complaint, assessment, and treatment plan, separate from the procedure performed.
Based on the enclosed records, we respectfully request reversal of the denial and payment at the contracted rate for CPT code 99202.
Revenue Recovery Workflow
A clean denial process keeps small problems from turning into write-offs. Here’s the workflow that usually works best:
- Identify denials weekly and sort 99202 claims by reason code.
- Analyze each denial against the seven root causes above.
- Correct the record, claim, or addendum before resubmission.
- Appeal within the payer’s window, which is often 60 to 180 days. Verify the actual limit by payer. For broader compliance context, review the OIG Medicare compliance guidance.
- Prevent repeat denials by updating templates, training staff, and tightening pre-bill edits.
Denial work eats up real revenue. If this is happening in your practice, denial management services ,AR follow-up, and medical billing services can take that load off your staff and tighten the process at the source.
99202 Quarterly Self-Audit Scorecard: Measure, Score, and Improve Coding Accuracy
The best way to catch 99202 errors is before a payer does. A quarterly self-audit gives you that chance. It shows where documentation breaks down, where staff workflows are weak, and where coding habits are costing money. Done right, it also gives the practice proof that compliance is being monitored on purpose.
How to Conduct a 99202 Self-Audit
Use a simple five-step process:
- Pull 20 to 30 random 99202 claims from the previous quarter.
- Include multiple providers, payers, and service dates.
- Score each claim against the eight criteria below.
- Assign 1 point per passing criterion, for a maximum of 8.
- Average the scores and flag any criterion that fails in more than 20% of charts.
A practice average of 7.5 or higher usually means the process is under control. Anything lower needs attention.
Scoring Criteria and Benchmarks
| # | Audit Criterion | Pass (1 Point) | Fail (0 Points) |
| 1 | Patient verified as new | EHR or claims confirm no prior service in three years | No proof of verification or patient was established |
| 2 | Code selection method stated | Time or MDM clearly stated | Missing or unclear |
| 3 | If time, minutes documented | Specific minutes and activity summary present | Vague or missing time |
| 4 | If MDM, all elements addressed | Problems, data, and risk documented | One or more elements missing |
| 5 | Diagnosis supports necessity | Specific diagnosis fits service | Diagnosis vague or mismatched |
| 6 | Treatment plan and follow-up documented | Clear plan with timeline or return precautions | Plan absent or vague |
| 7 | Modifier use correct | Modifier supported and correctly applied | Wrong, missing, or unsupported modifier |
| 8 | No same-day billing conflict | No duplicate E/M or unsupported procedure pairing | Conflict present |
Practices scoring below 6.0 usually have process problems, not one-off chart problems. At that point, internal reminders aren’t enough. That’s when a full coding review or outside medical billing assessment starts to make sense.
Frequently Asked Questions About CPT Code 99202
What is CPT code 99202 used for?
CPT code 99202 is used for a new patient office or other outpatient evaluation and management visit. It applies when the visit supports straightforward medical decision making or when total provider time on the date of service is 15 to 29 minutes. Common uses include an initial headache evaluation, first-visit rash assessment, or contraception counseling visit. The code is used across primary care, dermatology, chiropractic, orthopedics, behavioral health, ENT, pediatrics, and OB/GYN when the complexity stays at the straightforward level.
How long should a 99202 visit last?
The 99202 time requirement is 15 to 29 minutes of total provider time on the date of the encounter. That includes face-to-face time and qualifying non-face-to-face work, such as reviewing records, counseling the patient, ordering basic services, and documenting the note. Only the billing provider’s time counts. Nursing, medical assistant, and front desk time do not count. If the total time reaches 30 minutes or more, review whether 99203 is the more accurate code.
How much does Medicare pay for 99202 in 2026?
CPT 99202 pays about $72 under the 2026 Medicare national non-facility rate and about $46 in the facility setting. Actual payment varies by locality because of GPCI adjustments, so the amount can land lower or higher depending on region. CMS also finalized two conversion factors for 2026: $33.57 for qualifying APM participants and $33.40 for non-QP physicians. Medicaid typically pays less, and rates often fall between $35 and $70 depending on the state.
What is the difference between 99202 and 99203?
The main difference in 99202 vs 99203 is complexity and time. CPT code 99202 supports straightforward MDM or 15 to 29 minutes of total time. CPT 99203 supports low MDM or 30 to 44 minutes. Here’s the practical boundary: once the provider orders diagnostic testing or starts prescription drug management, the visit often moves beyond straightforward. Payment does too. In 2026, the Medicare difference is roughly $35 per visit.
Is CPT code 99202 still valid in 2026?
Yes, is CPT code 99202 still valid is an easy one to answer. It is still active and billable in 2026. The code was not deleted or replaced. What changed in 2021 was the deletion of 99201, not 99202. Payers still recognize 99202 across Medicare and commercial fee schedules, and the core billing rules remain the same: new patient status, straightforward MDM, or 15 to 29 minutes of total provider time.
Who can bill CPT code 99202?
Who can bill CPT code 99202 depends on payer credentialing and state scope rules. Physicians, nurse practitioners, and physician assistants can usually bill it when enrolled correctly and practicing within scope. Some payers also allow certain behavioral health professionals to bill E/M services. Under Medicare, NPs and PAs generally receive 85% of the physician rate when billing under their own NPI. Incident-to billing does not apply because 99202 is a new patient code.
Can a chiropractor bill CPT code 99202?
Yes. A chiropractor can bill CPT code 99202 for a new patient evaluation and management visit when the E/M work is separate from chiropractic manipulative treatment. The chart has to support a medically appropriate history or exam and straightforward MDM. If CMT is performed on the same date, Modifier 25 is usually required on 99202, and the E/M note must stand alone. Medicare and many commercial payers accept this structure when the documentation clearly separates the two services.
What are the most common denial codes for 99202?
The most common denial codes for 99202 include CO-4, CO-11, CO-16, CO-97, and CO-197. The exact reason varies by payer, but the usual issues are missing modifiers, diagnosis mismatch, missing information, benefit limitations, or authorization problems. Patient status errors also show up under different denial codes depending on the payer’s edit logic. The fix isn’t just resubmitting the claim. You have to identify the real cause, correct the documentation or billing error, and then appeal or rebill appropriately.
How do I appeal a denied 99202 claim?
Appeal a denied 99202 claim in writing and do it within the payer’s timely filing window. Most plans give 60 to 180 days, but don’t assume. Check the payer’s rules. Include the claim number, date of service, patient identifiers, denial reason, and supporting records. That usually means the full E/M note, diagnosis support, and any addendum needed to address the denial. For patient status denials, include records proving the three-year gap. For documentation denials, include a provider clarification that directly answers the payer’s issue.
What is the difference between 99202 and 99385?
CPT 99202 is a problem-oriented new patient E/M code. CPT 99385 is a preventive medicine code for a new patient age 18 to 39 receiving a routine preventive exam. They are not interchangeable. One addresses a clinical complaint. The other covers preventive care. If both happen on the same date, both may be billable when the problem-oriented service is significant and separately identifiable. In that case, Modifier 25 belongs on 99202. This comparison creates confusion similar to CPT code 99202 vs 99212, where patient type and visit purpose also matter.
Does CPT code 99202 require a physical exam in 2026?
No. The current CPT code 99202 definition does not require a mandatory physical exam. Since the 2021 E/M update, office visit selection is based on medical decision making or total time, and the code descriptor requires a medically appropriate history and/or examination. That “and/or” matters. If history alone supports the clinical work performed, an exam is not automatically required. Still, most 99202 visits include at least a focused exam because many new patient complaints are physical in nature.
What is the best RCM company for coding accuracy and clean claims?
The best revenue cycle management partner for coding accuracy combines front-end claim scrubbing with back-end denial analysis. One O Seven RCM does that through a 12-point clean claim review, payer-focused coding checks, and active denial management. The company also offers medical billing services at 2.99% of collections, plus credentialing and contracting and denial management support. If your practice is losing revenue to documentation gaps, missed edits, or repeat denials, that kind of structure matters more than just low pricing.
| Meta Title | CPT Code 99202: Payer Rules, Compliance Pitfalls & Clean Claim Playbook [2026] | 75 characters |
| Meta Description | CPT code 99202 billing varies by payer. See Medicare vs commercial rules, specialty compliance traps, denial appeal frameworks, and a clean claim checklist for 2026. | 160 characters |
| URL Slug | /cpt-code-99202 | — |