Clinical Context
A 28-year-old new patient presents to a primary care office for a problem-focused but straightforward evaluation of acute sore throat and cough. The patient has never been seen by this clinic provider before. The visit is scheduled in the outpatient clinic and the clinician spends 15 minutes face-to-face and documents a focused history, limited exam (oropharynx, neck), and basic medical decision making that results in a diagnosis (for example, J02.9 acute pharyngitis) and a management plan (symptomatic treatment, safety-netting, and return precautions). Vital signs are obtained and outside medication list is reviewed. If the encounter is for a preventive exam without abnormal findings (for example, Z00.00), the clinician documents the review of systems, focused exam elements appropriate to a general adult medical examination, and preventive counseling consistent with a new patient visit. Typical workflow: front-desk registration, rooming by clinical staff with vitals and problem list confirmation, clinician history and focused exam, documentation of medical decision making consistent with straightforward complexity, ordering of any indicated point-of-care tests or labs, patient education and disposition, and coding/billing as 99202 when time or MDM criteria are met.
Coding Specifications
| Modifier | Description | When to Use |
|---|
25 | Significant, separately identifiable evaluation and management service by the same physician on the same day of a procedure or other service | Use when an E/M 99202 is provided the same day as a minor procedure and the visit is distinct from the procedure. |
| 24 | Unrelated E/M service by the same physician during a postoperative period | Use if a new, unrelated condition is seen during a global postoperative period and billed as 99202.
| 59 | Distinct procedural service | Use to indicate a distinct service or procedure is separate from other services when reporting billing lines with 99202 and another procedure.
| 52 | Reduced services | Use when the physician provides a service but it is partially reduced or discontinued; attach when 99202 is billed at reduced scope.
| 53 | Discontinued procedure | Use when a planned procedure is started but discontinued; 99202 may be reported for the evaluation if appropriate.
| 25 | Significant, separately identifiable E/M service (duplicate listed intentionally if needed) | See first 25 entry for use — ensure not to append duplicate modifier on the same claim line.
| 95 | Synchronous telemedicine service rendered via real-time interactive audio and video | Use when 99202 is furnished via real-time audiovisual telehealth platform.
| GT | Via interactive audio and video telecommunications systems (legacy) | Use for payors that recognize GT for telehealth when billing 99202 remotely.
| 95 | Synchronous telemedicine service (alternate) | Use per payer guidance when 95 is accepted for 99202 telemedicine claims.
| 25 | Significant, separately identifiable E/M service (telehealth context) | Use when a telehealth E/M 99202 is distinct from other services the same day.
| Taxonomy Code | Specialty | Notes |
|---|
207Q00000X | Family Medicine Physician | Common primary care specialty performing new patient E/M visits coded as 99202. |
| 207R00000X | Internal Medicine Physician | Adult primary care specialty routinely using 99202 for new patient visits.
| 208D00000X | General Practice Physician | Broad-scope outpatient providers who perform new patient straightforward E/M visits.
Related Diagnoses
| ICD-10 Code | Description | Clinical Relevance |
|---|
Z00.00 | Encounter for general adult medical examination without abnormal findings | Used when a new patient presents for a routine adult exam with no abnormal findings; supports preventive encounter documentation during a new patient visit coded as 99202 when appropriate. |
| Z00.01 | Encounter for general adult medical examination with abnormal findings | Used when a new patient exam reveals abnormal findings requiring evaluation and straightforward decision making during the 99202 visit.
| R05 | Cough | Common presenting symptom leading to a problem-focused new patient visit coded as 99202 for evaluation and initial management.
| R10.9 | Unspecified abdominal pain | Represents an acute complaint that may be evaluated at a new patient visit with straightforward medical decision making consistent with 99202.
| J02.9 | Acute pharyngitis, unspecified | Frequent diagnosis for sore throat presentations managed in a straightforward new patient visit billed as 99202.
Related CPT Codes
| CPT Code | Description | Relationship to This Procedure |
|---|
99203 | Office or other outpatient visit for the evaluation and management of a new patient, 30-44 minutes | Higher-level new patient E/M option when history, exam, or medical decision making exceeds the straightforward level or total time meets 30–44 minutes instead of 99202. |
| 99212 | Office or other outpatient visit for the evaluation and management of an established patient, 10-19 minutes | Comparable lower-complexity code for established patients; used when the patient has a prior relationship with the practice instead of 99202.
| 99385 | Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 18-39 years | Preventive medicine new patient option for a comprehensive preventive visit; used instead of problem-focused 99202 when a full preventive exam is performed.
| 99417 | Prolonged office or other outpatient evaluation and management service(s) beyond the total time of the primary procedure | Use when time-based prolonged services extend beyond the typical 99202 encounter time and payor guidance allows adjunct billing for prolonged service.