CPT Code 99202: Guidelines, Considerations, and Requirements

Are you getting denials over the CPT code 99202? Read this blog to find out exactly what you’re doing wrong. We have covered a lot of details about this code including guidelines and billing considerations.

You can also check out the documentation requirements that you must fulfill while assigning it. Contact Health Quest Billing and ensure a smooth flow of approved claims with top-quality medical coding.

What Is CPT Code 99202?

The CPT code 99202 is a medical procedural code that comes under the New Patient range. This code is maintained by the American Medical Association. It is assigned to the office visits and other outpatient visits of new patients.

These visits are based on the evaluation and management services of healthcare providers. They also include straightforward medical decision-making. You must spend 15 or more minutes of your total time on these encounters on a single date.

The full form of CPT in medical coding is Current Procedural Terminology. This name is associated with specific numeric codes that are assigned to medical services. Healthcare providers and insurance companies use CPT codes to identify those services while billing them.

Key Guidelines for Assigning CPT Code 99202

There are some key guidelines set that you must follow while assigning the CPT code 99202. Let’s take a look at them in detail:

• New Patient Requirement

A “new patient” is someone who has not received any professional services from a physician. There is also no other physician of the same specialty in the same group practice within the past three years. Consider a patient who has visited a cardiologist within the same practice two years ago.

In this case, that patient would not be considered new. The term “professional services” refers to face-to-face encounters. These encounters take place between the physician and the patient. They do not just have phone calls or consultations without examination.

An example would be a patient who comes to the clinic for the first time. Their provider can use the CPT 99202 code for their first visit. The patient should have no history of receiving services from another doctor in the same practice and specialty.

• Straightforward Medical Decision Making

The medical decision-making involved during the visit must be straightforward. This means that the problems addressed are generally simple or self-limited. The decision-making process is minimal. You only have to evaluate a few data points and there is minimal risk of complications or mortality.

There may be one or more minor conditions. Typically, you only have to review minimal data like basic lab tests or possibly no data at all. The level of risk is also low. The risk of prescribing over-the-counter medications for minor conditions is an example.

Consider an example of a new patient who visits with a simple issue. Their issue is an allergic reaction to a known allergen. The physician should evaluate the situation and prescribe an antihistamine. This would qualify as straightforward decision-making.

• Time-Based Criteria

Billing 99202 requires providers to spend a total of 15 to 29 minutes on the visit on the same day. This includes not just face-to-face time spent with the patient. They also have to conduct non-face-to-face activities. Such activities include reviewing patient records before the visit.

You also have to document findings and write clinical notes after the visit. Order or review tests as well as follow up on the results related to the same visit. There are some activities done without the patient present. They include reviewing labs and coordinating care in this time.

Consider a provider who spends 10 minutes talking with the patient about their symptoms. There are 5 minutes spent documenting the encounter as well. Another 5 minutes are taken to review lab results. This total of 20 minutes qualifies the visit under CPT 99202.

• Comprehensive History and Exam Not Required

For CPT 99202, there is no requirement to perform an in-depth or comprehensive history or physical exam. The evaluation may involve only a problem-focused history and a brief physical exam. They can be appropriate for straightforward and low-complexity conditions. The physician may perform a limited examination tailored to the patient’s complaint.

They may not have to conduct an extensive or head-to-toe assessment. Think of a patient who presents with symptoms of a common cold. You may only take a brief history and perform a limited exam for them. You do not need to conduct a comprehensive exam.

• Encounter Documentation

You must thoroughly and accurately document an encounter even if it is relatively simple. Such documents can support the medical necessity of the visit and the time spent. The documentation should include the reason for the visit. A description of the straightforward medical decision-making must also be involved.

You can document the total time spent on the encounter as well. This can include both face-to-face and non-face-to-face time. The total time spent between 15 and 29 minutes also has to be documented. While doing this, you can specify how much of that time was spent in various activities.

An example of this guideline can be a record in a patient’s file. The record mentions their reviewed history and a physical exam performed. The provider also discussed treatment options for seasonal allergies. In the end, the total time spent on the encounter is 20 minutes.

Billing Considerations for CPT Code 99202

You must also be aware of certain considerations while billing claims associated with the CPT code 99202. Here is a detailed explanation of the primary ones:

• Verification in Different Practice Settings

You can apply the CPT code 99202 after classifying your patient as a “new patient.” A patient is considered new if they have not received any professional services from the same physician. They also have not been treated by another physician of the same specialty in the same group practice within the past three years.

There are some clinics that have different specialties under the same practice. Their patients can see another physician of a different specialty and still be considered new. Consider a patient who had previously seen a cardiologist. They are now visiting a general practitioner within the same practice.

You can qualify this as a new patient visit. This is important for billing as assigning CPT 99202 incorrectly for an established patient can result in claim denials. Billing teams need to track the specialty of physicians and the services received in the past three years. This way, they can ensure correct classification.

• Limited Data Review and Documentation

This code is unlike higher-level codes like CPT 99203 or CPT 99204. Those codes involve moderate or extensive data review. Whereas, CPT 99202 applies when there is minimal or no review of external data. This is because the problems addressed are typically simple or straightforward.

An example can be a patient visiting with a sore throat. They may have no lab tests performed or might have only a basic test like a rapid strep test. There is typically no need for advanced diagnostics or imaging studies. Billing staff must ensure that the physician’s notes and documentation reflect this minimal review of data.

The physician may order multiple tests or engage in a more extensive review of previous medical records. In this case, the visit might need to be billed under a higher-level code. Claim audits may flag discrepancies if a straightforward code like 99202 is used with complex documentation.

• Simple Encounter Justification

To bill CPT 99202, the visit should address simple or low-complexity issues. The diagnosis should be straightforward and not involve complicated medical problems. For instance, common diagnoses for CPT 99202 may include minor acute illnesses.

A patient may come in with a cold. Their physician will prescribe some over-the-counter cold medication. This qualifies as a straightforward medical decision. The medical records should reflect that the patient’s issue was self-limited and simple.

Billing personnel should carefully verify that your documents align with the simple visits. You would require a different code in case of more complex conditions. Using CPT 99202 incorrectly can easily lead to claim denials.

• Single or Few Diagnoses

CPT 99202 is typically used for visits involving one or two diagnoses. These diagnoses are generally minor. They can be easily resolved or managed within a single visit. For example, a patient presents with a minor rash and mild allergic reaction.

They could fall under CPT 99202. But a patient with multiple complex conditions would not fall under it. A patient may present with a simple sprain. The physician might diagnose and treat the issue in one visit. They may not need additional tests or referrals.

When billing CPT 99202, it is important to ensure that the diagnosis list is limited. A visit with more than two diagnoses might require a higher-level CPT code such as 99203 or 99204. You should review patient notes before submitting claims.

• Minimal Risk Interventions

One of the defining features of CPT 99202 is low-risk interventions or treatments provided. These may include simple instructions or recommendations for over-the-counter medications. A physician may recommend a common over-the-counter medication to patients with mild symptoms. They may also provide simple follow-up care.

It is considered low-risk and suitable for CPT 99202. It is crucial to document that the interventions were low-risk. You should also record that they did not involve more invasive or risk-laden procedures. For example, a visit may require a prescription for narcotics or other controlled medications.

The patient may also be referred for surgery. In this case, a higher-level CPT code might be necessary. Incorrect coding can result in audits or claim denials. The documentation might suggest a higher risk than what CPT 99202 allows.

Documentation Requirements for CPT Code 99202

Healthcare providers must also fulfill certain requirements in terms of their documentation. We have listed some of those requirements below:

• Pre-Visit Activities

Before a patient visit, healthcare providers often review their prior medical records. They also review lab results or consult with other healthcare professionals. These activities are not directly part of the face-to-face encounter. But they are essential for understanding the patient’s medical history.

This pre-visit work counts toward the total time spent on the patient’s care under CPT 99202. Providers must document these activities clearly. This ensures that they are accounted for in the total visit time (15-29 minutes). Without this documentation, the total time may appear less. 

• Patient Education

During the visit, providers often take time to educate the patient. They are educated about their condition, treatment options, or preventive care. You may advise a patient on how to manage their cold symptoms. You may also explain why they should take prescribed medications in straightforward visits.

Documenting the patient education given during the visit is also crucial. It shows the time and effort spent addressing the patient’s concerns. It also serves as a record for what the patient was instructed to do. Such records help to support medical necessity.

• Care Counseling and Coordination

In some cases, the provider may engage in counseling. It can be lifestyle advice or they may also coordinate care with other professionals. Even in relatively simple visits, counseling and care coordination can be necessary. This especially applies to conditions like smoking cessation or weight management.

Counseling or coordinating care must also be documented. It ensures that these efforts are reflected in the time spent with the patient. It also supports the medical necessity of the visit. Proper documentation also helps in ensuring continuity of care. This is helpful if the patient sees other healthcare providers.

• Social and Family History

Social and family history can have a significant impact on a patient’s health. For example, a patient’s family may have a history of asthma. It is also possible that the patient may be a smoker.

These factors may influence their diagnosis and management plan. Keep in mind that the CPT code 99202 does not require an extensive history. Still, the documentation of relevant social and family history is important.

This documentation provides context for the provider’s medical decision-making. It also ensures a more holistic understanding of the patient’s health. It also helps support the rationale for treatments or preventive advice.

• Use of Technology

You may use basic diagnostic tools for straightforward visits under CPT 99202. They are usually used to assess the patient’s condition. For example, checking a patient’s temperature or oxygen saturation can rule out more serious conditions. It can also provide additional insights into their health.

Minimal data review is required for CPT 99202. Using simple diagnostic tools supports the accuracy of the diagnosis and treatment plan. Documenting these tools ensures that the visit is thoroughly captured. It also provides a basis for the clinical decisions made during the visit.

The Bottom Line

This blog delved into the CPT code 92202 and how healthcare providers can accurately assign it. We looked at its key guidelines with it alongside the billing considerations that must be followed while assigning it.

The blog also focused on the documentation requirements that have to be fulfilled to accurately assign this code. Contact Health Quest Billing to ensure that you accurately assign CPT codes to your medical services.