CPT 99202–99205 in 2026: The New-Patient E/M Decision Guide

Schedule Your Free Consultation

How to select, document, and audit new-patient E/M codes without undercoding revenue away or overcoding your way into an audit.

Quick Answer:  CPT 99202–99205 report new patient office/outpatient visits, selected either by medical decision making (MDM) straightforward, low, moderate, or high or by total time on the date of service (roughly 15–29, 30–44, 45+, or 60+ minutes respectively). The code must match whichever pathway the documentation actually supports; a long note or a long diagnosis list doesn't by itself justify a higher level.

Key Takeaways

•     A patient is “new” only if no professional service was provided by that physician — or another physician of the same specialty/subspecialty in the same group — within the past 3 years.

•     MDM level depends on 2 of 3 elements: problems addressed, data reviewed, and risk — not the number of diagnoses listed.

•     Time-based coding uses total time on the date of service, not just face-to-face minutes — and it must be documented, not estimated after the fact.

•     Undercoding and overcoding are both revenue-integrity problems — one leaves legitimate money unclaimed, the other creates audit and recoupment exposure.

•     Note length is not a coding criterion; a template-generated long note without matching clinical decision-making is a recognized audit flag.

•     G2211 has its own medical-necessity and documentation logic — it isn't an automatic add-on to every new-patient visit.

The First Question: Is the Patient Actually New?

Under current AMA/CMS guidance, a patient is new if they haven't received a professional service from that specific physician — or another physician of the exact same specialty and subspecialty in the same group practice — within the prior 3 years. A patient who saw a different provider in the same specialty at your group 18 months ago is established, even if they've never met the provider seeing them today. A diagnostic interpretation alone (reading an X-ray, for example) generally doesn't establish a professional service relationship that makes a later visit “established.” Commercial payers can define this differently — verify payer-specific policy when it's ambiguous.

Common Mistake:  Assuming new-patient status based on whether the patient is new to the specific provider, without checking whether anyone else of the same specialty in the group saw them within the last 3 years.

The 99202–205 Decision Matrix

Verify current thresholds against AMA CPT guidance before billing — these reflect the 2021 E/M framework as updated through 2024.

The Three MDM Elements

1. Problems Addressed

What matters is what was actually managed at this encounter — not every diagnosis on the patient's problem list. A stable chronic condition mentioned in passing is not the same as an acute exacerbation actively managed that day.

2. Data Reviewed and Analyzed

Ordering a test, independently interpreting a tracing, reviewing outside records, or discussing a case with another treating professional all count — but the review and its effect on the plan need to be documented, not just implied by an order in the chart.

3. Risk of Complications, Morbidity, or Mortality

Risk is tied to the actual management decision — starting or adjusting a prescription drug, deciding on a procedure, or choosing to monitor closely — not the diagnosis in the abstract.

Common Mistake:  Treating five listed diagnoses as automatic proof of high-complexity MDM. Complexity comes from active management of the problems addressed that day, not the length of the problem list.

Time vs. MDM: Choosing the Right Pathway

Method	Best Used When	Common Error
MDM	Documentation clearly shows 2 of 3 elements at a given level, regardless of visit length.	Selecting a level based on note length instead of the actual elements documented.
Total time	The bulk of the (medically necessary) work was cognitive/administrative rather than complex decision-making.	Counting only face-to-face minutes, or including unrelated administrative tasks.

Both pathways exist for the same encounter, and they can point to different levels — 55 minutes with two high-complexity elements might support 99205 by MDM but only 99204 by time. Choose whichever pathway is actually documented and supported; never the one that simply pays more.

Why Undercoding and Overcoding Are Both Problems

Issue	What It Looks Like	Consequence
Undercoding	Habitually defaulting to a lower code regardless of documented complexity.	Legitimate revenue never claimed — often invisible until an audit finds the pattern.
Overcoding	Billing a level the note doesn't actually support.	Recoupment risk, payer scrutiny, and audit exposure.

Expert Insight:  The most effective E/M coding improvement programs don't start by telling providers to “code higher.” They start by finding where real clinical decision-making is already happening but isn't showing up clearly in the note.

G2211: When It May (and May Not) Apply

G2211 recognizes the added complexity of being a patient's continuing, longitudinal focal point of care — it isn't an automatic add-on to every new-patient E/M visit. It fits scenarios involving ongoing management of a serious or complex condition, not a one-time or episodic encounter. Confirm current CMS guidance on eligible scenarios and modifier 25 interaction before billing it routinely.

Documentation-to-Code Alignment

A billing team reviewing the note should be able to identify the specific problems addressed, the data reviewed, and the risk-based decision made — without inferring them from a long assessment or a template-generated review of systems. Copy-forward text and unsupported templated findings are a recognized audit flag precisely because they decouple the note's length from the actual clinical work.

Common 99202–205 Failure Points

•     Selecting a code based on note length rather than the documented MDM elements or time.

•     Assuming every ordered test automatically raises the data complexity level.

•     Using time without documenting the total minutes and what the time covered.

•     Confusing face-to-face time with total time on the date of service.

•     Diagnosis lists that don't match what the assessment and plan actually addressed.

Pre-Bill and Post-Payment Audit Workflow

•     Pre-bill: verify new-patient status, confirm the MDM elements or time are documented, and check that the diagnosis matches the assessment.

•     Post-payment: sample a rolling set of claims across all four codes and compare the note against what was billed.

•     Retrospective: look for systematic patterns — a provider who never bills 99205, or one whose distribution skews unusually high — and address the root cause with documentation feedback, not a directive to “code higher.”

E/M Revenue Integrity Dashboard

Code distribution and benchmarks are practice- and specialty-specific — track your own trend rather than a universal target.

KPI	What It Reveals
Code distribution (99202–205)	Whether coding patterns look clinically plausible for your patient mix.
Documentation exception rate	How often notes fail to support the code billed on review.
E/M denial rate	Whether front-end status verification and coding accuracy are working together.
Corrected claim rate	How much rework is happening after initial submission.

30-Day New-Patient Coding Improvement Plan

Days	Focus
1–10	Baseline audit of recent new-patient claims; identify documentation gaps.
11–20	Provider education on the specific gaps found; implement pre-bill QA review.
21–30	Analyze denials and coding variance; establish ongoing monitoring.

How MedCloudMD Can Help

MedCloudMD's coding specialists work on the areas covered in this guide new-patient status verification, MDM and time documentation review, pre-bill coding QA, denial management, and post-payment audits with certified coders and human review built into the workflow.

Request a Free E/M Coding Audit:  If you're not sure how your new-patient coding distribution or documentation is actually holding up, our specialists can review a sample with you.

Explore our Medical Coding Services, or talk with our billing specialists to discuss your current E/M workflow.

Frequently Asked Questions

What are CPT codes 99202–99205?

They report new patient office/outpatient E/M visits, ranging from straightforward (99202) to high complexity (99205), selected by medical decision making or total time on the date of service.

What is the difference between 99202, 99203, 99204, and 99205?

Each represents a higher MDM complexity level and a higher time threshold straightforward through high complexity with the code determined by whichever documented pathway (MDM or time) the encounter actually supports.

How do you determine whether a patient is new for E/M billing?

A patient is new if they haven't received a professional service from that physician, or another physician of the same specialty/subspecialty in the same group, within the past 3 years.

Can MDM determine the level of a new-patient E/M visit?

Yes — MDM level is based on 2 of 3 elements: problems addressed, data reviewed and analyzed, and risk of complications from the management decisions made.

Can time be used to select 99202–99205?

Yes. Total time on the date of the encounter — not just face-to-face time — can determine the code when it's documented and reflects the medically necessary work performed.

What documentation supports a 99205?

Either two of three MDM elements at high complexity, or 60–74 documented minutes of total time, with the note showing the actual problems, data, and risk-based decisions involved.

What are the most common 99202–99205 billing errors?

Coding by note length instead of documented MDM elements, miscounting data complexity, confusing face-to-face with total time, and diagnosis lists that don't match the documented assessment.

How can practices audit new-patient E/M claims?

With a pre-bill review checking status and documentation, a rolling post-payment sample comparing notes to billed codes, and a retrospective review for systematic coding patterns across providers.

How can a medical billing company improve E/M coding accuracy?

By pairing certified coding review with provider documentation feedback addressing gaps in the note rather than simply directing providers to code higher or lower.

What Practices Should Do Now

1.   Verify new-patient status against the 3-year, same-specialty/same-group rule.

2.   Review MDM documentation for the actual problems, data, and risk — not the diagnosis list.

3.   Use time only when it's documented and reflects the real work performed.

4.   Audit new-patient claims on a regular cadence, not just after a denial.

5.   Give providers documentation feedback, not a directive to code higher.

 Last Reviewed: August 2026. CPT guidance, CMS policy, and payer rules are updated periodically — this page will be reviewed as those change.

Disclaimer: This content is provided for educational purposes only and should not be considered legal, coding, reimbursement, compliance, or medical advice. CPT® coding guidance, CMS policy, and payer rules can change and vary by payer, state, and contract. This article does not replace the current CPT® manual, applicable payer policy, or the judgment of a qualified coding or compliance professional. Verify current requirements before submitting any claim. MedCloudMD provides professional medical billing and revenue cycle management services but does not guarantee reimbursement outcomes or search ranking/indexing results.