New Patient Office Visit (CPT Codes 99201-99205): Coverage and Documentation Requirements


This Comparative Billing Report (CBR) focuses on physicians who submit claims for New Patient Office Visit (E/M) Services (CPT codes 99201-99205). CBR information is one of the many tools used to assist individual providers to become proactive in addressing potential billing issues and performing internal audits to ensure compliance with Medicare guidelines.

For your personalized New Patient Office Visit (E/M) Services (CPT codes 99201-99205) eCBR results, log on to eServices.

New Patient Office Visit (E/M) Services (CPT Codes 99201-99205) - Overview of Key Components
The key components of E/M including those services billed for New Patient Office Visit (E/M) Services

  1. History
  2. Examination
  3. Medical decision-making

New Patient Office Visit (E/M) Services (CPT 99201-99205) - Documentation Requirements

CPT Code
Description
Documentation Requirements
99201
Typically 10 minutes
  • Problem focused history
  • Problem focused exam
  • Straightforward medical decision making

(Based on straightforward medical decision making)

Minimal number of diagnoses or management options;

None or minimal amount and/or complexity of data to be reviewed;

Minimal risk of significant complications, morbidity and/or mortality or

Limited number of diagnoses or management options;

Limited amount and/or complexity of data to be reviewed; low risk of significant complications, morbidity and/or mortality

99202
Typically 20 minutes
  • Expanded Problem focused history
  • Expanded Problem focused exam
  • Straightforward medical decision making

(Based on straightforward medical decision making)

Minimal number of diagnoses or management options;

None or minimal amount and/or complexity of data to be reviewed;

Minimal risk of significant complications, morbidity and/or mortality or

Limited number of diagnoses or management options;

Limited amount and/or complexity of data to be reviewed; low risk of significant complications, morbidity and/or mortality

99203
Typically 30 minutes
  • Detailed history
  • Detailed Examination
  • Low-complexity medical decision making

(Based on low- complexity medical decision making)

Minimal number of diagnoses or management options;

None or minimal amount and/or complexity of data to be reviewed;

Minimal risk of significant complications, morbidity and/or mortality or

Limited number of diagnoses or management options;

Limited amount and/or complexity of data to be reviewed; low risk of significant complications, morbidity and/or mortality

99204
Typically 45 minutes
  • Comprehensive history
  • Comprehensive Examination
  • Moderate medical decision making

(Based on moderate medical decision making)

Multiple number of diagnosis or management options;

Moderate amount and/or complexity of data to be reviewed;

Moderate risk of significant complications, morbidity and/or mortality

99205
Typically 60 minutes
  • Comprehensive history
  • Comprehensive Examination
  • High complexity medical decision making

(Based on high complexity medical decision making)

Extensive number of diagnosis or management options;

Extensive amount and /or complexity of data to be reviewed;

High risk of significant complications, morbidity and/or mortality

Education Resources:
The Provider Outreach and Education (POE) team has developed a web-based training to address the issues pertinent to New Patient Office Visit codes. Your practice is being advised to view the WBT using the following link: Interactive Tool: New Patient Office Visits Module  

Methods:
The metrics reviewed in this CBR are the proportion of billing for each HCPCS code in the E/M grouping with comparisons to peers within the state and Jurisdiction M (JM). This report is an analysis of Medicare Part B claims extracted from the Palmetto GBA data warehouse. The analysis shows the portions of your New Patient Office Visit family of codes (CPT codes 99201-99205) claims at each level compared to your peers in JM.

Example of eCBR Results from eServices:

eCBR Lookup New Patient Office Visits Screen Display

Please be aware that the information contained within this CBR is not intended to be punitive or an indication of fraud. Rather, it is intended to be proactive communication that will assist you in identifying potential billing issues and help you with performing a self-audit of your conformity with Medicare guidelines.





Last Updated: 02/07/2018