Office o/p est sf 10 min
CPT 99212 is billed for a brief follow-up office visit with an established patient, typically lasting 10 minutes. This is one of the most commonly used codes for routine check-ups, minor problem visits, or medication refills.
RVU breakdown
Conversion factor: 32.3465 · Source: CMS MPFS RVU25A · Confidence: High
Billing tips
Accurately differentiate between 99212 and 99213 based on medical decision making or time. 99213 requires moderate complexity or 20-29 minutes.
Impact: Undercoding with 99212 when 99213 is appropriate costs $82.06 per encounter (99213 pays $137.05 vs 99212 at $54.99). For practices seeing 50 patients daily, proper level selection can impact annual revenue by $750,000+
Document total time on date of encounter when using time-based billing. Include all pre-service, face-to-face, and post-service time (reviewing records, ordering tests, documentation).
Impact: Time documentation supports 99212 when MDM doesn't clearly support the level; visits between 10-19 minutes qualify. Missing time documentation leads to downcoding to 99211 (loss of $27.57 per visit)
When billing 99212 with modifier 25 on same day as procedure, document the separate nature of the E&M service clearly, including distinct diagnoses when possible.
Impact: Proper modifier 25 documentation prevents denial of the E&M service entirely, protecting $54.99 per encounter. Payers audit modifier 25 heavily; 30-40% of claims may face denial without clear separation
Verify established patient status before billing 99212. Patient must have received professional services from same physician/group within past 3 years.
Impact: Billing 99212 for new patient encounters results in denial and rebilling as 99202, creating payment delays and administrative costs of $15-25 per correction
Ensure medical necessity is clearly documented. The problem addressed must warrant a face-to-face encounter, not just administrative communication.
Impact: Medical necessity denials require costly appeals and may result in zero payment. Approximately 8-12% of 99212 denials cite lack of medical necessity
For split/shared visits in facility settings, document which provider performed which portions and ensure the physician personally performs substantive portion.
Impact: Proper split/shared documentation allows billing at physician rate ($33.96 facility rate) rather than incident-to restrictions. Compliance prevents Medicare fraud allegations
Common denials
Billed as established patient but medical records show patient is new (no encounter within 3 years or different specialty in same group)
How to appeal: Submit appeal with documentation proving prior encounter within 3 years by same physician or same-specialty group member. Include medical records with dates of service. If truly new patient, accept denial and rebill with appropriate new patient code 99202-99205
Insufficient documentation to support level of service (documentation supports only 99211 or nurse visit)
How to appeal: Review documentation for presence of medical decision making elements: problem addressed, data reviewed, or risk level. If time was the determining factor, submit addendum documenting total time spent. If documentation truly insufficient, accept downcoding and improve future documentation
Modifier 25 denial - E&M service not separately identifiable from procedure performed same day
How to appeal: Provide detailed appeal letter explaining how E&M addressed separate problem or exceeded typical pre/post-procedure work. Include documentation showing distinct diagnosis codes when applicable. Highlight specific E&M elements beyond procedure's usual work
Service bundled into global surgical period from unrelated provider
How to appeal: Append modifier 24 (unrelated E&M during postop period) or 79 (unrelated procedure during postop) as appropriate. Submit operative report from original surgery and current visit notes demonstrating unrelated condition. Include clear explanation of why current service is outside global package
Frequently asked questions
How much does CPT 99212 reimburse from Medicare in 2025?
Medicare pays $54.99 for CPT 99212 in non-facility settings (private offices) and $33.96 in facility settings (hospital outpatient departments) based on the 2025 national average. Actual payment varies by geographic location due to locality adjustments. Commercial insurance typically pays 150-250% of Medicare rates.
What is the difference between CPT 99212 and 99213?
99212 requires straightforward medical decision making or 10-19 minutes of total time, while 99213 requires low complexity MDM or 20-29 minutes. 99213 typically involves more problems (2+ stable conditions or 1 worsening chronic illness), more data review, or higher risk. The reimbursement difference is significant: 99213 pays $137.05 versus 99212 at $54.99 (Medicare 2025).
Can you bill 99212 for a telehealth visit?
Yes, 99212 can be billed for telehealth visits when provided via real-time interactive audio and video. Append modifier 95 to indicate telehealth delivery. Medicare currently pays the non-facility rate of $54.99 for telehealth E&M services through existing telehealth flexibilities. Documentation requirements remain the same as in-person visits.
How many minutes is required for CPT 99212?
CPT 99212 requires 10-19 minutes of total time on the date of encounter when using time-based coding. This includes pre-service work (reviewing records, preparing), face-to-face time, and post-service work (documentation, care coordination, ordering). If using medical decision making instead of time, there is no specific time requirement, only straightforward complexity.
What RVU value does 99212 have?
CPT 99212 has a total RVU of 1.7 for 2025, consisting of 0.7 work RVU, 0.95 non-facility practice expense RVU (0.3 facility PE RVU), and 0.05 malpractice RVU. When multiplied by the 2025 conversion factor of 32.3465, this yields the Medicare payment of $54.99 non-facility.
Can you bill 99212 with modifier 25?
Yes, modifier 25 should be appended to 99212 when a significant, separately identifiable E&M service is performed on the same day as a procedure. The E&M must be beyond the usual pre/post-procedure work. Documentation must clearly show the separate nature of the visit, ideally with different diagnosis codes. This allows full payment for both services.
What documentation is needed for CPT 99212?
Documentation must support either straightforward medical decision making (1 minor problem or stable chronic illness, minimal data, low risk) or 10-19 minutes of total time. Required elements include chief complaint, history of present illness, examination findings relevant to the problem, assessment, and plan. Provider must document established patient status and sign the note with credentials.