CurrentOptumPolicy N/A

Reimbursement for New Patient and Initial Visit E/M Codes

Governs Optum reimbursement rules for New Patient Evaluation and Management (E/M) and Initial Visit CPT codes for claims billed on CMS 1500, electronic 837p submissions, and provider portals across commercial, Medicare, and Individual Exchange plans, for network and non-network providers.

Policy Summary

PayerOptum

PolicyReimbursement for New Patient and Initial Visit E/M Codes

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit accurate claims using procedure codes that correctly describe services provided.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

CMS1500/837pclaim types covered

Commercial/Medicare/Exchangeplan products

3 yearsNew Patient timeframe

Same Specialty checkInitial Visit rule

CPT/CMScoding references

Reimbursement Criteria

Reimbursement criteria for New Patient and Initial Visit codes

Covered when ALL of the following are met:

Patient meets the definition of New Patient: has not received any professional services (E/M or other face‑to‑face) from the physician, or another physician of the same specialty in the same group practice, within the past 3 years.

When billing a New Patient E/M CPT code, the elements of the New Patient definition must be met for reimbursement.

Initial Visit CPT codes are reimbursed only when the Same Specialty Physician has not previously reported the same Initial Visit CPT code or any CPT code described as a Subsequent Visit for the same patient.

An encounter provided by an on‑call or covering physician who bills under the same Federal Tax Identification number is classified as it would have been by the unavailable physician and does not automatically qualify the patient as a New Patient.

Policy Summary

PayerOptum

PolicyReimbursement for New Patient and Initial Visit E/M Codes

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit accurate claims using procedure codes that correctly describe services provided.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Claims Submission & Billing Guidance

Documentation Required

Claims submission responsibility — submit accurate, properly coded claims

Submit accurate claims using the procedure code(s) that correctly describe the health care services provided for members whose behavioral health benefits are administered by Optum (including UnitedHealthcare) and OptumHealth Behavioral Solutions of California; this policy applies to services billed on CMS 1500 forms and electronic 837p submissions and claims submitted through provider portals. Optum may consider coding guidance, benefits design, provider contracts and regulatory requirements when applying this policy.

Use CPT, CMS or other procedure coding guidelines as appropriate to describe services.
Ensure claims are submitted on the appropriate claim form or electronic format (CMS 1500, 837p) or via provider portal.
Be aware Optum may exercise discretion in interpreting and applying the policy and other factors may affect reimbursement.

Key Definitions

Same Specialty Physician

DefinitionPhysician and/or Other Qualified Health Care Professional of the same group and same specialty reporting the same Federal Tax Identification number

IncludesAll physicians and/or other qualified health care professionals of the same group reporting the same Federal Tax Identification number

Use for reimbursement determinationUsed to determine whether another provider’s prior service disqualifies a visit as New Patient or Initial Visit

New Patient

DefinitionA patient who has not received any professional services (E/M or other face-to-face) from the physician, or another physician of the same specialty in the same group, within the past three years

Determines eligibility forNew Patient E/M code reimbursement

ExceptionEncounter with on-call or covering physician billing under the same Federal Tax Identification number is classified as it would have been by the unavailable physician and does not automatically qualify as a New Patient visit

Initial Visit

DefinitionThe first patient encounter for a specific purpose (e.g., the first E/M visit or the first annual wellness visit)

Reimbursement ruleInitial Visit CPT codes reimbursed only when the Same Specialty Physician has not previously reported the same Initial Visit CPT codes or a CPT code described as a Subsequent Visit for the same patient

Source guidanceDefinition follows Centers for Medicare and Medicaid Services (CMS) description

Subsequent Visit

DefinitionAny encounter that occurs after the initial patient encounter for a specific purpose

Relationship to Initial VisitSubsequent Visit codes indicate follow-up encounters and can preclude reimbursement of an Initial Visit code if previously reported by the Same Specialty Physician

Use in codingDetermines whether an encounter is classified as initial versus subsequent for reimbursement purposes

99202	New Patient E/M (mapped from list)
99203	New Patient E/M (mapped from list)
99204	New Patient E/M (mapped from list)
99205	New Patient E/M (mapped from list)
99341	New Patient E/M
99342	New Patient E/M
99343	New Patient E/M
99344	New Patient E/M
99345	New Patient E/M

OpenPayer

Reimbursement for New Patient and Initial Visit E/M Codes

Reimbursement Criteria

Relevant CPT Codes and Lookback

Claims Submission & Billing Guidance

Key Definitions