CPT Code 99202

(2022) CPT Code 99202 – Description, Billing Guidelines & Clinical Examples

This article will define CPT Code 99202, explain the medical necessity to report CPT 99202, the guidelines and clinical examples of CPT 99202.

CPT Code 99202 Description

CPT Code 99202 is defined by the CPT manual as follows (the text in Italic is the official definition of CPT 99202):

Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components:

Component 1: An expanded problem focused history

Component 2: An expanded problem focused examination

Component 3: Straightforward medical decision making

Counselling and/or coordination of care with other providers 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 of low to moderate severity.

A new patient is a patient who has not received any professional services from the physician in the last three years or in the case where a physician / qualified medical professional is on call for another physician / qualified medical professional represents another physician / qualified healthcare professional, the patient encounter is classified as it would have been conducted by the unavailable qualified physician / healthcare professional.

Physicians typically spend 20 minutes face-to-face with the patient and/or family.

Expanded problem focused history

Documentation needed:

Main complaint

Brief history of the disease in question

Problem-related systems review

Expanded problem focused examination

Documentation needed: Limited examination of affected body area or organ system and other symptomatic or related body areas or organ systems.

Medical decision making that is straightforward

Documentation needed (2 of 3 below must be met or exceeded)

Minimum number of diagnoses or treatment options

Minimal or no quantity and / or complexity of data to verify

Minimal risk of significant complications, morbidity and / or mortality

Billing Guidelines CPT Code 9920199205

CPT codes 92002 – 92014 are used for medical examinations and evaluations with the initiation or continuation of a diagnosis and treatment program.

Intermediate services for CPT codes 92002 – 92012 describe an evaluation of a new or existing condition that is complicated by a new diagnosis or management problem, with the initiation of a diagnosis and treatment program.

This includes medical history, general medical observation, external eye and adnexal examinations, and other diagnostic tests, if applicable (including mydriasis for ophthalmoscopy).

Comprehensive services include a general examination of the entire visual system and always include the initiation of diagnostic and treatment programs.

These services are classified in relation to E / M services, although the earlier transitions from ophthalmic services to E / M services no longer exist.

Still, the reviews provide some understanding of the type of medical decision making (MDM) to expect. CPT 92002 is closest to CPT 99202 and 92004 (MDM low or medium) is between CPT code 9920399204 (MDM medium to high).

Evaluation And Management CPT Codes

A limited number of E / M codes would be sent to a health department, including:

CPT code 99201

CPT code 99202

CPT code 99203

CPT code 99211

CPT code 99212

CPT code 99213

These codes are used for new patients (CPT Codes 99201 – 99203) and established patients (CPT Codes 99211 – 99213) if they are treated in practice and / or on an outpatient basis.

There are also preventive medical codes that can be used to report preventive medical evaluations of infants, children, and adults. These visits will not be a problem as they are ‘good’ preventive visits. These codes are defined as new or established patient and by age.

2021 Updates For CPT Code 99202

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.

Medicare would pay another one-time fee for established patient codes 9921299214. Level 5 visits (CPT 99205 and 99215) would have separate fees to reflect the greater complexity of these codes.

CPT 99202 RVUs

The following table shows total RVUs for Q1 2021 and Q 2020 for CPT code 99202. RVUs for MPFS facilities are often lower than RVUs for non-facility (office) because the physician is responsible for less practical costs if a physician provides services in a facility.

Final reimbursement amounts for E / M services don’t just depend on these RVUs.

2020 Q4 RVUs – 2.14 (Non-Facility) – 1.43 (Facility)

2021 Q1 RVUs – 2.13 (Non-Facility) – 1.42 (Facility)

CPT 99202 Examples

Example 1

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)

Example 2

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)

Example 3

Initial office visit for a patient with a circumscribed patch of dermatitis of the leg. (Dermatology)

Example 4

Initial office visit for a patient with papulosquamous eruption of elbows. (Dermatology)

Example 5

Initial office visit for a 9-years-old patient with erythematous grouped, vesicular eruption of the lip of three days duration duration. (Pediatrics)

Example 6

Initial office visit for an 18-years-old male referred by an orthodontist for advice regarding removal of four wisdom teeth. (Oral & Maxillofacial Surgery)

Example 7

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)

Example 8

Initial office visit for a patient presenting with itching patches on-the wrists and ankles. (Dermatology)

Example 9

Initial office visit for a 30-years-old male for evaluation and discussion of treatment of rhinophyma. (Plastic Surgery)

Example 10

Initial office visit for a 16-years-old male with severe cystic acne, new patient. (Dermatology)

Example 11

Initial office evaluation for gradual hearing loss, 58-years-old male, history and physical examination, with interpretation of complete audiogram, air bone, etc. (Otolaryngology)

Example 12

Initial evaluation and management of recurrent urinary infection in female. (Internal Medicine)

Example 13

Initial office visit with a 10-years-old girl with history of chronic otitis media and a draining ear. (Pediatrics)

Example 14

Initial office visit for a 10-years-old female with acute maxillary sinusitis. (Family Medicine)

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)

Example 16

Initial office visit for a 25-years-old patient male with a single season allergic rhinitis. (Allergy & Immunology) 

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