99202 CPT code is an office or other outpatient visit code that is typically reported daily and is differentiated as new or established patients. There are four levels under the services of office or other outpatient visits for the new patient category represented by 99202-99205. These codes report office or other outpatient services for only new patients. This article will help you with proper coding, Billing guidelines, Modifiers, and reimbursement for CPT code 99202.
According to medical coding and billing guidelines, A new patient is the one who has never received professional services from a physician, another physician or other qualified healthcare professionals for three years within the same specialty and practicing group.
A medically appropriate history and physical examination should be documented as determined by the treating provider. The right level of history and physical examination is no longer used when determining the level of service.
Codes should be selected based on the current CPT Medical Decision Making table. Alternately, time alone may be used to determine the appropriate level of service. Total time for reporting these services includes face-to-face and non-face-to-face time personally spent by the practitioner or other health care professionals on the date of the encounter.
Providers report this CPT code 99202 for new patients being seen in the Doctor’s office, a multispecialty group clinic, or other outpatient environments. Furthermore, CPT code 99202 is the most basic service, which entails straightforward MDM. While using time for code selection, 15-29 minutes of the total time is spent on the date of the encounter.
CPT code 99202 -Office or other outpatient visits for a new patient’s E&M (Evaluation & management) requires a medically appropriate history, examination, and straightforward MDM (Medical decision making). When using time for selecting the level of E&M code, then it should be between 15-29 minutes spent on the date of the encounter.
Select the appropriate level of E/M services based on the following:
- The story of the MDM as defined for each service, or
- The total time for Evaluation and Management services performed on the encounter date.
Medical Decision Making includes making a diagnosis, assessing the severity or complexity of the condition, and selecting a treatment.
Selection Criteria of CPT 99202:
- An expanded problem focused history
- An expanded issue-focused examination
- Straightforward medical decision making.
Medical Decision Making for New Patient
Following are the key components to make a correct level of outpatient or office visit encounters with new patients:
- The number and complexity of the problem that is reported during the encounter.
- The complexity of data to be analyzed and reviewed, including medical records, lab testing, and other information that must be obtained and ordered for the encounter.
Coordination of care and Counseling with other providers or agencies are provided consistent with the nature of the problem and the patient’s or his family’s demand.
For E&M codes 99202 CPT code to 99205, all of the face-to-face and non–face-to-face time spent by the billing clinician on the day of the visit should be counted. Counseling should never be more than 50% of the total time.
Often, the presenting problem is of low to moderate severity. A doctor typically spends 20 minutes confronting the patient or family.
Only Medicare’s medically necessary portion of low complexity of the visit is allowed for CPT code 99202.
Furthermore, To determine the level of an E&M code for an office visit or outpatient dept. Only the requisite services for the patient’s condition during the encounter can be considered, Even if a complete note is generated. Medical necessity must be clearly stated and support the level of service reported.
Documentation should include the history and exam performed in addition to the medical decision-making performed. When time is the determinant for code selection, total time should be documented. Medical necessity must be clearly stated and support the level of service reported.
Although not used to determine code selection, history and exam performed should be documented. Medical decision-making performed should be noted. Medical necessity must be clearly stated and support the level of service reported.
Report these services with place-of-service code 11, representing the clinician’s office location, or 22, designating an outpatient setting. When a separately identifiable service is performed on the same day with CPT code 99202, then modifier 25 should be appended to the 99202 CPT code to indicate the service as distinct from the other procedures or services performed on that date of service.
when services are provided in a physician’s office space or on the hospital campus, and that physician’s office space is not part of a provider-based department of the hospital.
On Campus-Outpatient Hospital
99202 CPT Code Billing Guidelines
According to billing guidelines, only one unit per visit of CPT code 99202 is allowed.
The level of E&M service billed must be based on the treatment of a low level of complexity (having one self-limited or minor problem and straightforward MDM) performed concerning the medical care required by the reported symptoms and resulting in the patient’s diagnosis.
The Cost and total RVUs of CPT code 99202 are $49.49 and 1.43000, respectively for both National and Global Facility Services.
The Cost and total RVUs of 99202 CPT code are $74.06and 2.14000, Respectively, for both National and Global Non-Facility Services.
Facility codes reflect the volume and ferocity of resources used by the facility to provide care.
99202 CPT Code 2021 Updates
One policy change in the 2019 MPFS final rule that received a good response from providers was the plan to pay a one-time fee called a combined fee.
Medicare intended to pay the same fee for the new patient CPT codes 99202 – 99204, regardless of which code was reported.
99202 CPT Code Modifiers
Modifiers provide additional information about the medical procedure, service, or supply involved without changing the meaning of the code.
Modifiers that are applicable with CPT code 99202 are given below:
- 24, 25, 27, 33, 57, 93, 95, 99, AI, AQ, AR, CC, CR, CS, ET, EY, FR, G0, GA, GC, GE, GJ, GK, GQ, GR, GT, GU, GY, GZ, KX, Q5, Q6, QJ, TH.
Modifiers often used in medical coding and billing for CPT 99202 are 24, 25, 57, 95, and GT.
Modifier 25 with Example
Separate identifiable E&M service performed by the Same Physician or Other Qualified Health Care Professional on the Same Day when another minor or major procedure is performed.
Use modifier 25 on an E/M service performed during the same session as a preventive care visit when significant, separately identifiable E/M service is rendered in addition to the preventive care.
Use modifier 25 always when the Evaluation and management service is Distinct, significantly identifiable, and separately documented as another service different from the E&M service.
A patient came to the Doctor’s office for evaluation and management of Osteoarthritis of the hip, and the Doctor aspires 2ml synovial fluid from the hip joint. In this case, modifier 25 would be appended to the CPT code 99202, describing the E&M as a separate procedure.
Modifier 57 with Example
57- “Decision for surgery.” An E&M service resulted in the decision to perform the significant/major surgery identified by using a 57-modifier to the appropriate level of E/M service.
Use Modifier 57 to indicate an Evaluation and Management (E/M) service when the initial decision to perform surgery is the day before major surgery (90 days global) or the day of major surgery.
A patient came to the Doctor’s office for Mild pain and abdominal tenderness, but an ultrasound revealed 4cm of benign neoplasm of the large intestine. The Doctor performed a tissue biopsy and decided to remove the neoplasm the next day. So, in this case, modifier 57 should be appended to CPT code 99202 on the day when the biopsy was done and the Doctor took the decision for major surgery.
Modifier 24 with Example
Unrelated E&M service given by the Same Physician or Other Qualified Health Care Professional During a global period (postoperative) of an effective procedure.
Modifier 24 is appended with the E&M code when a patient is in the global fee period of a major or minor procedure performed within the global fee period. Still, They returned for a different condition or procedure with another Diagnosis code.
A patient had surgery of Achilles tendon tenotomy two months ago, and he came to the same Doctor’s office for evaluation and management of sustained hypertension. So, in this case, sustained hypertension is a new problem, so we will append modifier 24 with the E&M code to distinguish it as an unrelated E&M service.
Modifier 95 and GT
Both modifiers have almost the same description and use. These are Synchronous Telemedicine Services provided through a Real-Time Interactive video or audio Telephonic, or telecommunication approach. Only the difference is Modifier 95 is used for Commercial insurance, and GT is used for Medicare.
Telemedicine service is a real-time interaction of a physician with the patient who is located far away from the physician’s office. The information exchanged between the patient and physician or other qualified health care professionals during the telephonic communication service must be sufficient to meet the key components and requirements of the service when provided via direct face-to-face interaction.
So modifier 95 or GT should be appended to E&M service rendered via a telecommunication system.
CPT Code 99202 Examples
The following are examples of when 99202 CPT code may be billed.
Initial office visit for a 13-years-old patient with come do papular acne of the face unresponsive to over-the-counter medications. (Family medicine)
Initial office visit for a patient with a clinically benign lesion or nodule of the lower leg that has been present for many years. (Dermatology)
Initial office visit for a patient with a circumscribed patch of dermatitis of the leg. (Dermatology)
Initial office visit for a patient with papulosquamous eruption of elbows. (Dermatology)
Initial office visit for a 9-years-old patient with erythematous grouped, vesicular eruption of the lip of three days duration duration. (Pediatrics)
Initial office visit for an 18-years-old male referred by an orthodontist for advice regarding removal of four wisdom teeth. (Oral & Maxillofacial Surgery)
Initial office visit for a 14-years-old male, who was referred by his orthodontist, for advice on the exposure of impacted maxillary cuspids. (Oral & Maxillofacial Surgery)
Initial office visit for a patient presenting with itching patches on-the wrists and ankles. (Dermatology)
Initial office visit for a 30-years-old male for evaluation and discussion of treatment of rhinophyma. (Plastic Surgery)
Initial office visit for a 16-years-old male with severe cystic acne, new patient. (Dermatology)
Initial office evaluation for gradual hearing loss, 58-years-old male, history and physical examination, with interpretation of complete audiogram, air bone, etc. (Otolaryngology)
Initial evaluation and management of recurrent urinary infection in female. (Internal Medicine)
99202 CPT Code Example 13
Initial office visit with a 10-years-old girl with history of chronic otitis media and a draining ear. (Pediatrics)
99202 CPT Code Example 14
Initial office visit for a 10-years-old female with acute maxillary sinusitis. (Family Medicine)
99202 CPT Code Example 15
Initial office visit for a patient with recurring episodes of herpes simplex who has developed a clustering of vesicles of the upper lip. (Internal Medicine)
99202 CPT Code Example 16
Initial office visit for a 25-years-old patient male with a single season allergic rhinitis. (Allergy & Immunology)