Summary & Overview
CPT 99202: Office Visit for New Patients, Straightforward Decision Making
CPT code 99202 is a foundational billing code for office or outpatient visits involving the evaluation and management of new patients. It is widely used across the United States by primary care and general practice physicians to document encounters that require a medically appropriate history and/or examination, with straightforward medical decision making. The code is selected when the total time spent with the patient meets or exceeds 15 minutes, making it a key metric for both clinical documentation and reimbursement.
Major national payers, including Aetna, Blue Cross Blue Shield, Cigna Health, Medicare, and UnitedHealthcare, recognize and reimburse for services billed under CPT 99202. This publication provides an overview of the code’s clinical context, typical site of service, and its role in the evaluation and management of new patients. Readers will gain insight into relevant benchmarks, policy updates, and the broader implications for medical billing and compliance. The summary also highlights related codes and modifiers commonly used in conjunction with CPT 99202, offering a comprehensive perspective for healthcare professionals and administrators.
Understanding CPT 99202 is essential for accurate billing, compliance, and quality reporting in outpatient care settings. The code’s straightforward requirements make it a standard for documenting new patient visits, ensuring consistency across payers and clinical practices nationwide.
CPT Code Overview
CPT 99202 is used to report an office or other outpatient visit for the evaluation and management of a new patient. This code applies when the encounter requires a medically appropriate history and/or examination and straightforward medical decision making. When selecting this code based on total time, the visit must meet or exceed 15 minutes on the date of the encounter.
Service Type: Evaluation and Management – New Patient Office or Other Outpatient Visit
Typical Site of Service: Office or other outpatient settings, such as place of service 11.
Clinical & Coding Specifications
Clinical Context
A new adult patient presents to a physician's office for an initial evaluation. The visit includes a medically appropriate history and/or examination, and the medical decision making is straightforward. The encounter may address general health concerns, such as a routine check-up, or specific symptoms like cough, abdominal pain, or sore throat. The total time spent with the patient on the date of the encounter meets or exceeds 15 minutes. The service is provided in an office or other outpatient setting, and may be delivered in person or via synchronous telemedicine, depending on patient needs and provider capabilities.
Coding Specifications
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Modifier
25: Used when a significant, separately identifiable evaluation and management service is performed by the same physician on the same day as another procedure or service. -
Modifier
95: Indicates that the service was rendered via a real-time interactive audio and video telecommunications system (synchronous telemedicine).
| Provider Taxonomy Code | Specialty Name |
|---|---|
207Q00000X | Family Medicine Physician |
207R00000X | Internal Medicine Physician |
208D00000X | General Practice Physician |
Related Diagnoses
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Z00.00: Encounter for general adult medical examination without abnormal findings- Used for routine check-ups where no abnormalities are found during the examination.
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Z00.01: Encounter for general adult medical examination with abnormal findings- Used when a general medical examination reveals abnormal findings that require further evaluation.
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R05: Cough- Relevant for visits where the patient presents with cough as a primary symptom.
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R10.9: Unspecified abdominal pain- Used when the patient reports abdominal pain without a specific diagnosis at the time of the visit.
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J02.9: Acute pharyngitis, unspecified- Applicable for visits where the patient presents with symptoms of sore throat or pharyngitis without a specified cause.
Related CPT Codes
| CPT Code | Description | Relationship to 99202 |
|---|---|---|
99203 | Office or other outpatient visit for the evaluation and management of a new patient, 30-44 minutes | Used for new patient visits requiring more time and/or higher complexity than 99202. |
99212 | Office or other outpatient visit for the evaluation and management of an established patient, 10-19 minutes | Used for established patients; not typically billed with 99202 but relevant for comparison. |
99385 | Initial comprehensive preventive medicine evaluation and management, new patient; 18-39 years | Used for preventive visits; may be an alternative to 99202 when the visit is preventive in nature. |
99417 | Prolonged office or other outpatient evaluation and management service(s) beyond the total time of the primary procedure | Used in conjunction with 99202 if the time spent exceeds the threshold for prolonged services. |
National Reimbursement Benchmarks
For CPT code 99202, the national mean rate for Medicare is $77.68, while the average commercial benchmark (BUCA) is $79.74. Commercial payers such as UnitedHealth Group and Cigna report higher mean rates, at $98.19 and $89.66 respectively, compared to both Medicare and BUCA.
Rate dispersion, measured by the difference between the 75th and 25th percentiles, varies across payers. Medicare shows the tightest range at $7.00, indicating less variability in rates. In contrast, UnitedHealth Group has the widest dispersion at $51.67, followed by Cigna at $44.00, reflecting greater variability in commercial reimbursement rates.
The table and chart below present a detailed breakdown of national benchmarks for each payer, including mean rates and percentile values.
State Benchmarks
State: AK1 / 50
Alaska Benchmarks
Alaska exhibits a wide spread in reimbursement rates for CPT code 99202 across payers, with UnitedHealth Group offering the highest mean rate at $163.99 and Medicare the lowest at $75.56. The rate spread, calculated as the difference between the 75th and 25th percentiles, is most pronounced for Cigna ($70.21) and Blue Cross Blue Shield ($34.00), indicating substantial variability in commercial payer rates. UnitedHealth Group's rates are tightly clustered, with the 25th, 50th, and 75th percentiles all at or above $164.00, suggesting consistent high reimbursement.
Compared to national averages, Alaska's commercial payers consistently reimburse at higher rates, with mean rates for Aetna, Blue Cross Blue Shield, Cigna, and UnitedHealth Group all well above their national benchmarks. The table and chart below present the full breakdown of payer-specific rates for CPT code 99202 in Alaska.
Key Insights for Alaska
- UnitedHealth Group is the highest paying payer for CPT 99202 in Alaska, with a mean rate of $163.99.
- Medicare is the lowest paying payer, with a mean rate of $75.56, notably below the commercial payers.
- All commercial payers in Alaska reimburse at rates significantly above their respective national averages, with UnitedHealth Group showing the largest deviation.
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