New Patient Visit Code: Usage, Billing Guide, and Common Pitfalls
In medical billing, accurately using Evaluation and Management (E/M) codes is critical for ensuring timely reimbursement and avoiding costly denials. One such vital set of codes is for New Patient Visits, generally ranging from 99202 to 99205 under CPT® guidelines. In this article, we’ll break down what these codes mean, when and how to use them, what to avoid, and key steps to successful billing.
🩺 What Is a New Patient Visit Code?
A new patient is defined as someone who has not received any professional services from the provider (or another provider of the same specialty in the same group practice) within the past 3 years.
The New Patient Visit CPT Codes are:
- 99202 – 15–29 minutes
- 99203 – 30–44 minutes
- 99204 – 45–59 minutes
- 99205 – 60–74 minutes
⚠️ Note: These codes are based on either time spent or medical decision making (MDM) as per 2021 E/M guidelines.
📋 When to Use a New Patient Visit Code
Use a new patient E/M code when:
- The patient is new to the provider or practice.
- The visit involves initial assessment, diagnosis, and care planning.
- The visit includes a face-to-face interaction with a physician or qualified healthcare professional.
🧠 How to Use New Patient Visit Codes: Key Criteria
As per the updated E/M guidelines:
1. By Time (Including non-face-to-face time):
- Pre-visit review
- Counseling and educating the patient
- Care coordination
2. By Medical Decision Making (MDM):
- Number and complexity of problems
- Amount and/or complexity of data reviewed and analyzed
- Risk of complications and/or morbidity/mortality
🧑⚕️ Example: A new patient with two chronic conditions and lab data reviewed might justify a 99204 based on MDM.
🚫 What to Avoid When Billing New Patient Codes
Improper use can lead to claim denials, audits, or downcoding. Here are common pitfalls to avoid:
❌ Using it for established patients:
- If the patient was seen by another provider in the same group with the same specialty in the last 3 years, use an established patient code (99212–99215) instead.
❌ Lack of documentation:
- Documentation must clearly support the level of service, whether by time or MDM.
❌ Upcoding:
- Billing a higher-level code (e.g., 99205) without justification can trigger audits.
❌ Ignoring shared/split visit rules:
- In facility settings, ensure proper attribution when services are shared between providers (physician + NP/PA).
✅ Key Steps to Accurately Bill a New Patient Visit Code
- Verify patient status – Confirm no visits in 3 years.
- Choose billing method – Based on time or MDM.
- Document thoroughly – Include all relevant history, decision making, and coordination activities.
- Use correct ICD-10 codes – Accurately reflect the diagnosis.
- Attach supporting documentation – Include labs, referrals, or previous records if necessary.
- Use correct NPI and modifiers – Especially if multiple providers are involved.
- Submit electronically – With all required fields and attachments.
🛑 Potential Denials for New Patient Visit Codes
Denials are often avoidable with proper preparation. Common reasons include:
| Denial Reason | Description |
|---|---|
| Duplicate billing | Another provider in the group billed recently for same patient |
| Missing documentation | No time log or insufficient MDM documentation |
| Incorrect code level | Code billed higher than documentation supports |
| Patient not eligible | Insurance inactive or plan exclusions |
| Provider not credentialed | With patient’s insurance |
📞 Tip: Use payer portals or IVRs to verify patient status and provider enrollment before submitting claims.
📊 Quick Reference: New vs. Established Patient
| Criteria | New Patient | Established Patient |
|---|---|---|
| Seen within 3 years? | ❌ No | ✅ Yes |
| CPT Codes | 99202–99205 | 99212–99215 |
| Reimbursement | Typically higher | Lower |
| Documentation Needed | More comprehensive | More focused |
🧾 Conclusion
Correctly billing for new patient visits is essential for accurate reimbursement and compliance. Understanding when and how to use these codes can save your practice from denials, audits, and revenue loss.
🔍 Remember: When in doubt, document more than less, and always verify payer-specific rules.
💬 Have More Questions?
Drop your questions in the comments or contact our billing experts. We’re here to help you optimize your revenue cycle.