This article will define CPT Code 99201, explain the medical necessity to report CPT 99201, the guidelines and clinical examples of CPT 99201.
CPT Code 99201 Description
CPT Code 99201 is defined by the CPT manual as follows (the text in Italic is the official definition of CPT 99201):
Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components:
- Component 1: A problem focused history
- Component 2: A problem focused examination
- Component 3: A straightforward medical decision making
Counselling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self limited or minor. Typically, 10 minutes are spent face-to-face with the patient and/or family.
Billing Instructions: Bill 1 unit per visit.
2021 Updates For CPT 99201 – 99205
AMA has revised the descriptions for evaluation and management (E / M) codes CPT 99201 –99215 in the 2021 Codebook Current Procedural Terminology. Existing guidelines were developed in 1995 – 1997 and continue to apply to all other E / M services as determined by medical history, examination, and decision making (MDM).
In 2021, for new and established outpatient and office services that are reported with codes CPT 99202 – 99215, a physician can select the code based on time or MDM.
There are three components in MDM, and two out of the three are required. These components are the quantity and complexity of the problems being reviewed, amount and / or complexity of data to be considered and analysed, and the risk of complications and / or morbidity and mortality of patient management.
CPT code 99201 has more definitive requirements than CPT 99211 when it comes to components of history, purgatives and medical decisions. Additionally, CPT 99201 should not be initiated for use with nursing visits, as the
physician must see the patient and establish a care plan before nursing visits can be billed.
CPT Code 99201 Examples
Initial office visit for a 50-years-old male from out-of-town who needs a prescription refill for a nonsteroidal anti-inflammatory drug. (Anesthesiology)
Initial office visit for a 40-years-old female, new patient, requesting information about local pain clinics. (Anesthesiology/Pain Medicine)
Initial office visit for a 40-years-old girl for determination of visual acuity as part of a summer camp physical (does not include determination of refractive error). (Ophthalmology)
Initial office visit for an out-of-down patient requiring topical refill. (Dermatology)
Initial office visit for a 65-years old male for reassurance about an isolated seborrheic keratosis on upper back. (Plastic Surgery)
Initial office visit for an 86-years-old male, out-of-down visitor, who needs prescription refilled for an anal skin preparation that he forgot. (General Surgery/Colon & Rectal Surgery)
Initial office visit for a patient with alveolar osteitis for repacking. (Oral & Maxillofacial Surgery)
Initial office visit for a patient with a pedunculated lesion of the neck which is unsightly. (Dermatology)
Initial office visit for a 10-years-old male, for limited subungual hematoma not requiring drainage. (Internal Medicine)
Initial office visit with an out-of-down visitor who needs a prescription refilled because she forgot her hay fever medication. (Allergy & Immunology/Internal Medicine)
Initial office visit with a 9-month-old female with diaper rash. (Pediatrics)
Initial office visit with a 10-years-old male with server rash and itching for the past 24 hours, positive history for contact with poison oak 48 hours prior to the visit.(Family Medicine)
Initial office visit with a 5-years-old female to remove sutures from simple wound placed by another physician. (Plastic Surgery)
Initial office visit for a 22-years-old male with a small area of sunburn requiring first aid. (Dermatology/family Medicine/Internal Medicine)
Initial office visit for the evaluation and management of a contusion of a finger. (Orthopedic Surgery)