Office o/p new sf 15 min
CPT 99202 is billed when a physician sees a new patient in the office for a straightforward medical problem that requires minimal history, examination, and decision-making, typically lasting 15-20 minutes.
RVU breakdown
Conversion factor: 32.3465 · Source: CMS MPFS RVU25A · Confidence: High
Billing tips
Use time-based coding when total time (15-29 minutes) supports 99202 but MDM documentation is marginal; document total time on date of encounter including care coordination, documentation, and other non-face-to-face activities
Impact: Ensures accurate code selection and reduces downcoding risk; improper time documentation is a leading cause of audits for E&M services
Verify new patient status (patient has not received professional services from the physician or another physician of the same specialty in the same group within the past 3 years); billing established patient codes when new patient criteria are met loses $22-45 in revenue per visit
Impact: 99202 pays $69.87 non-facility vs 99212 (established, straightforward) which pays approximately $52-58; miscoding loses $12-18 per encounter
When minimal history/exam is performed, ensure MDM elements are clearly documented: document the problem addressed, data reviewed (even if minimal), and risk level to support straightforward MDM
Impact: Prevents downcoding to 99201 equivalent or denials; clear MDM documentation is the primary defense against medical necessity denials
Consider whether 99203 (low complexity, 30-44 minutes) is more appropriate when managing prescription drugs or ordering/reviewing diagnostic tests; 99203 pays $111.56 non-facility, a $41.69 increase over 99202
Impact: Undercoding from 99203 to 99202 costs $41.69 per encounter; review MDM table to ensure accurate complexity assignment
For non-facility settings, confirm place of service code 11 (office) to receive the higher $69.87 rate versus $45.29 facility rate; incorrect POS coding loses $24.58 per visit
Impact: Place of service errors result in $24.58 underpayment per encounter; verify location meets non-facility criteria
When billing with modifier 25 on same day as procedure, document the separate and distinct nature of the E&M service with a clear indication that the visit addressed concerns beyond the procedure
Impact: Modifier 25 denials on 99202 can result in $69.87 loss per encounter; specific documentation of separately identifiable service is required for successful appeal
Common denials
Medical necessity not established - payer determines the documented problem does not warrant a new patient office visit or that the service was preventive rather than problem-oriented
How to appeal: Submit appeal with clinical documentation highlighting the acute or chronic problem addressed, symptom severity, and medical decision-making performed. Include relevant policy language defining medical necessity for E&M services and cite specific documented elements (chief complaint, assessment, plan) that demonstrate problem-focused care rather than preventive screening.
Incorrect patient status - billed as new patient (99202) when payer records show patient is established (should be 99211-99215)
How to appeal: Provide documentation proving new patient criteria: no professional services from this provider or same-specialty provider in the group within 36 months. Submit attestation from provider, practice records showing initial encounter, and request payer clarify their records if discrepancy exists. Note that different specialties within same group can bill as new patients.
Modifier 25 denial when 99202 billed same day as procedure - payer bundles E&M into procedure payment
How to appeal: Resubmit with detailed documentation showing the E&M service was separately identifiable and above/beyond the usual pre- and post-procedure work. Highlight distinct documentation of history, examination findings, and MDM unrelated to the procedure. Consider adding narrative appeal letter explaining the separate nature of services with timeline of visit activities.
Insufficient documentation - provider documentation does not support 99202 level (missing required MDM elements or time documentation)
How to appeal: If appeal-worthy, submit complete medical record with cover letter mapping documentation to 2023 E&M guidelines requirements for straightforward MDM (limited problem, minimal data, minimal risk) or 15-29 minutes total time. If documentation truly insufficient, accept denial, implement documentation improvement, and consider voluntary refund to avoid fraud implications.
Frequently asked questions
What is the Medicare reimbursement rate for CPT code 99202 in 2025?
The 2025 Medicare national average reimbursement for CPT 99202 is $69.87 for non-facility settings (office) and $45.29 for facility settings. These rates are based on a total RVU of 2.16 and the 2025 conversion factor of 32.3465. Actual payment may vary by geographic location based on locality-specific adjustments.
How long should a 99202 office visit take?
For time-based coding, CPT 99202 requires 15-29 minutes of total time on the date of encounter. This includes face-to-face time with the patient plus time spent on care coordination, medical record documentation, and communication with other providers. Alternatively, you can select 99202 based on straightforward medical decision-making regardless of time spent.
What is the difference between CPT 99202 and 99203?
CPT 99202 requires straightforward medical decision-making or 15-29 minutes total time, while 99203 requires low complexity medical decision-making or 30-44 minutes. The 99203 code is for slightly more complex new patient visits involving prescription drug management, ordering/interpreting tests, or addressing acute uncomplicated illness with systemic symptoms. The 2025 Medicare payment difference is $41.69 ($111.56 for 99203 vs $69.87 for 99202 in non-facility settings).
Can I bill 99202 for a telemedicine visit?
Yes, CPT 99202 can be billed for telemedicine visits when performed via real-time interactive audio and video telecommunications. Add modifier 95 (or GT for some payers) and verify the payer covers telehealth for this code. Medicare continues to cover 99202 via telehealth under current flexibilities, though policies may change. The reimbursement rate is typically the same as in-person visits during the public health emergency flexibilities.
What are the documentation requirements for CPT 99202?
Documentation must include a chief complaint, medically appropriate history/exam, and either straightforward medical decision-making (minimal problem, minimal data, minimal risk) or 15-29 minutes total time on the encounter date. You must also verify and document new patient status (no professional services from your specialty in your group within 3 years). The provider must sign and date the documentation.
Can I bill 99202 with a procedure on the same day?
Yes, you can bill 99202 with a procedure on the same day using modifier 25, but the E&M service must be separately identifiable and above the usual pre- and post-procedure work. Document the distinct evaluation clearly, showing that you addressed concerns beyond the procedure itself. Common pairings include 99202 with laceration repairs, injections, or minor skin procedures when a separate problem-focused evaluation occurred.
What is the RVU value for CPT 99202 in 2025?
CPT 99202 has a total RVU of 2.16 in 2025, consisting of 0.93 work RVU, 1.16 practice expense RVU (non-facility), 0.40 practice expense RVU (facility), and 0.07 malpractice RVU. These values are from the CMS Medicare Physician Fee Schedule RVU25A released December 23, 2024.