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Billing and coding

How to use CPT code 99202

CPT code 99202 represents a new patient appointment that’s at least 15 minutes in duration.

The 99202 code is an E/M code used by prescribing providers.

CPT code 99202 description

Code 99202 represents a new patient appointment that’s at least 15 minutes in duration. It’s a prescriber code, which means it’s most commonly used by psychiatrists or nurse practitioners. 

This is is how the American Medical Association defines 99202 in the official CPT codebook:

CPT code 99202: New patient office visit, minimum 15 minutes

Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 15 minutes must be met or exceeded.

As a prescriber, you can bill insurance according to time or medical decision-making (MDM). Make sure to include sufficient documentation to support the method you choose.

If you spent 15 minutes with a client but the case was especially complex or high risk, or involved reviewing or analyzing a lot of data, you may use a higher CPT code, including 99203 (low MDM), 99204 (moderate MDM), or 99205 (high MDM).

It’s important to use the code that most accurately reflects the time you spent with the patient to treat their condition, and ensure that documentation for the session supports the chosen code. 

99202 vs 99212: New patient vs. existing patient

If you’re treating an existing patient, you should use 99212 instead. A new patient is someone you have not seen in the last three years.

CPT code 99202 time frame

CPT code 99202 is a new patient appointment of at least 15 minutes. Other time frames for a new patient should be coded with [99203] (at least 30 minutes), [99204] (at least 45 minutes), or [99205] (at least 60 minutes).

CPT code 99202 documentation

Documentation for 99202 is essentially the same as other E/M codes, but geared toward a new patient. New patient notes should always include: 


  • Medically appropriate history: Document relevant information about the patient’s presenting complaint, medical history, and any other important factors.
  • Medically appropriate examination: Perform and document an evaluation that’s appropriate for the patient’s presenting complaint.
  • Straightforward medical decision making: Make a straightforward judgment about the patient’s diagnosis, create a care plan, and prescribe appropriate treatments or interventions.
  • If you are billing based on time, include start/stop timers.


Here’s a new patient example note:

Patient Name: Jane Smith

Date of Service: 03/16/2022

Patient DOB: 6/13/1990

Appointment Time: 11:30am-12:00pm


Place of Service: Patient was located at their home at 123 Main St Anywhere US 12345 

Provider was located at their office: 456 Storybook Ln Hollywood CA 96852 


This session was provided via a HIPAA compliant interactive audio/video platform. The patient consented to this telemedicine encounter.


The total time I spent caring for this patient today was 28 minutes which included: interviewing the client, documenting, reviewing the patient's responses to questionnaires, discussing treatment plans, coordinating care, prescription management and counseling the client on managing her mental health.

Subjective

Chief Complaint: Patient presents with a complaint of mild anxiety and occasional trouble sleeping.

HPI: 32-year-old female reports feeling mildly anxious over the past two months, mainly due to work-related stress. She experiences difficulty falling asleep about twice a week but denies waking up in the middle of the night. Denies other psychological symptoms, such as depression or mood swings.

ROS:

  • General: No recent weight changes, no fever or chills.
  • Cardiovascular: No chest pain or palpitations.
  • Neurological: No headaches, no dizziness.

PMH/PSH:

  • Past medical history: None significant.
  • Past surgical history: None.

Medications:

  • No current medications.

Objective

Physical Examination:

  • General: Alert and oriented, well-nourished.
  • HEENT: No abnormalities.
  • Lungs: Clear to auscultation bilaterally.
  • Heart: Regular rate and rhythm. No murmurs, gallops, or rubs.

Assessment

Diagnosis: Generalized Anxiety Disorder (mild).

Plan

Lifestyle modifications including improved sleep hygiene and relaxation techniques. Follow up in 4 weeks to assess progress.

  • Prescription: None.

Time spent: 20 minutes face-to-face.

Electronically signed by,

[Provider name, Credentials, Date signed]

CPT code 99202 reimbursement rates

Reimbursement rates for sessions billed with 99202 will vary depending on factors like the specific payer contract, your geographic location, and type of therapy license. Headway providers can check the portal for rates with each insurance provider.

Find out your rates with Headway

This document is intended for educational purposes only. It is designed to facilitate compliance with payer requirements and applicable law, but please note that the applicable laws and requirements vary from payer to payer and state to state. Please check with your legal counsel or state licensing board for specific requirements.

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