CurrentUnitedHealthcarePolicy 2025ROOAB

New Patient and Initial Visit E/M Coding Reimbursement

Defines UnitedHealthcare reimbursement rules for New Patient evaluation and management (E/M) codes and Initial Visit HCPCS codes for services billed on the CMS-1500 (and specified UB-04) forms, applying to Commercial and Individual Exchange plans and all network and non-network physicians and qualified health care professionals.

Policy Summary

PayerUnitedHealthcare

PolicyNew Patient and Initial Visit E/M Coding Reimbursement

Policy CodePolicy 2025ROOAB

Change TypeUpdated New Patient Codes Tabletemplate/application clarifications

Effective Date

Next Review Date

Key ActionSubmit accurate claims using the CMS-1500 or electronic equivalent; UB-04 may apply when specified.

SourceLink

POLICY UPDATE CHANGES

Updated New Patient Codes Table.

Policy template and application sections were updated to specify applicability to UnitedHealthcare Commercial and Individual Exchange benefit plans.

CMS-1500claim form applicability

3 yearslookback period

Commercial & Exchangeproduct lines

2/16/2025last table update

Reimbursement Criteria

Reimbursement criteria (encoded node)

UnitedHealthcare will reimburse New Patient E/M codes and Initial Visit HCPCS codes only when policy definitions and lookback conditions are met.

Reimbursement requires the policy definitions and lookback conditions below be satisfied.

ALL of the following

The patient must meet the CMS definition of a New Patient: the patient has not received any professional services (E/M service or other face-to-face service) from the physician, or another physician of the same specialty who belongs to the same group practice (same TIN), within the past three years.
‘Same Specialty’ and ‘Same Group’ are construed as physicians or other qualified health care professionals of the same specialty reporting under the same Federal Tax Identification Number (TIN).
If a physician is on-call or covering for another physician and is billing under the same TIN, the encounter is classified the same as it would have been by the physician who was not available; the patient is not considered a New Patient solely because the visit was with an on‑call physician.

Policy Summary

PayerUnitedHealthcare

PolicyNew Patient and Initial Visit E/M Coding Reimbursement

Policy CodePolicy 2025ROOAB

Change TypeUpdated New Patient Codes Tabletemplate/application clarifications

Effective Date

Next Review Date

Key ActionSubmit accurate claims using the CMS-1500 or electronic equivalent; UB-04 may apply when specified.

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.

New Patient and Initial Visit Codes

Covered CPT/HCPCS CodesmixedCovered

99202	New patient office/outpatient visit, typically 20 minutes
99203	New patient office/outpatient visit, typically 30 minutes
99204	New patient office/outpatient visit, typically 45 minutes
99205	New patient office/outpatient visit, typically 60 minutes
99341	Home visit for new patient, typically 15 minutes
99342	Home visit for new patient, typically 25 minutes
99343	Home visit for new patient, typically 35 minutes
99344	Home visit for new patient, typically 45 minutes
99345	Home visit for new patient, typically 60 minutes
99381	New patient preventive medicine, infant (well child)

1–10 of 20

1/2

New Patient lookback

New Patient lookback period3 years — A New Patient is one who has not received any professional services (E/M or other face-to-face service) from the same specialty physician or other qualified health care professional in the same group (same Federal Tax Identification number) within the past three years.

Claims Submission and Billing Rules

Billing Rule

Claims submission responsibility (CMS-1500; UB-04 when specified)

Submit accurate claims using the CMS-1500 form (or electronic equivalent). This reimbursement policy applies to services reported using the 1500 Health Insurance Claim Form (a/k/a CMS-1500) or its electronic equivalent; when specified the policy may also apply to UB-04 forms. Ensure claims reflect the codes that correctly describe the services provided.

Use CMS-1500 or electronic equivalent for reporting unless the policy specifically directs use of UB-04.
Claims must accurately describe the health care services provided per UnitedHealthcare reimbursement policy guidance.

Denial Risk

New patient determination and ED exception — 3‑year same specialty/TIN lookback

Do not bill New Patient E/M codes when the patient has received any professional services from the physician, or another physician of the same specialty who reports under the same TIN, within the past three years. Emergency department E/M services are not distinguished as new versus established by CPT and may be reported for any patient who presents for treatment.

New Patient status requires no professional services from same specialty/same TIN within the past 3 years.
On-call or covering physicians billing under the same TIN do not create New Patient status if the patient previously saw a physician in that same specialty/TIN.
ED encounters follow CPT guidance: CPT makes no distinction between new and established patients for emergency department services.

Key Definitions

Definition — New Patient

DefinitionA New Patient is a patient who has not received any professional services from the physician, or another physician of the same specialty who belongs to the same group practice (same TIN), within the past three years.

ScopeIncludes E&M services and other face-to-face professional services (e.g., surgical procedures)

On-call/coverage ruleA patient seen by an on-call or covering physician billing under the same TIN is NOT considered a New Patient solely because the covering clinician provided the service

Definition — Initial Visit

DefinitionAn Initial Visit is the first patient encounter for a specific purpose (e.g., first E/M visit, first annual wellness visit); reimbursed only when the Same Specialty/TIN has not previously reported the same Initial Visit HCPCS code or a HCPCS code described as a Subsequent Visit for the same patient.

Relation to Subsequent VisitA Subsequent Visit is any encounter that occurs after the initial patient encounter for that specific purpose; prior reporting of a Subsequent Visit HCPCS code by the same specialty/TIN precludes reimbursement of an Initial Visit code.

ExamplesIncludes first E/M visit, first annual wellness visit, first visit to discuss a specific condition (e.g., diabetic sensory neuropathy)

Definition — Same Specialty / Same Group

DefinitionPhysicians or other qualified health care professionals of the same specialty who report under the same Federal Tax Identification Number (TIN).

ImplicationServices billed by any clinician within the same specialty-group/TIN count toward the 3-year lookback for New Patient determination.

Reporting constructThe Same Group/Same Specialty construct uses the Federal Tax Identification Number to group clinicians for billing and status determination.