CPT Coding for New Patient Establishing Primary Care
For a new patient establishing primary care, use CPT codes 99201-99205, with the specific code selected based on the complexity and time of the encounter. 1
Code Selection Framework
The new patient office visit codes (99201-99205) are structured by increasing complexity and time requirements 1:
- 99201: Problem-focused history and exam, straightforward decision-making
- 99202: Expanded problem-focused history and exam, straightforward decision-making
- 99203: Detailed history and exam, low complexity decision-making
- 99204: Comprehensive history and exam, moderate complexity decision-making OR at least 45 minutes with more than half spent counseling 1
- 99205: Comprehensive history and exam, high complexity decision-making OR 60 minutes with more than half spent counseling 1
Key Coding Requirements
New patient visits require all three key components (history, physical examination, and medical decision-making) to be met for code selection, unlike established patient visits which require only two of three components 2. This is a critical distinction that affects proper code assignment.
Time-Based Coding Caveat
Only use time as the controlling factor when counseling or coordination of care dominates more than 50% of the visit 2. Do not default to coding based solely on time descriptors—the three key components should guide your selection in most encounters 2.
Common Pitfalls to Avoid
Undercoding is far more common than overcoding in primary care settings, with studies showing 72% of visits coded as 99213 or lower could have been billed at higher levels 3. This represents significant lost revenue for practices.
Resident physicians undercode more frequently (88.7% of encounters) compared to faculty (40.3%), often due to lack of familiarity with CMS coding rules or perceived burden of documentation requirements 3.
Do not confuse new patient codes with preventive care codes (99381-99394 for EPSDT/well visits), which are separate services 1. If both problem-focused care and preventive care occur during the same visit, use modifier 25 with the appropriate evaluation and management code 1.
Documentation Standards
Your documentation must support the level of service billed by clearly demonstrating the required components 2. For new patient establishment visits, ensure comprehensive documentation of:
- Complete medical history including past medical, family, and social history
- Review of systems appropriate to the complexity level
- Physical examination findings
- Assessment and medical decision-making complexity
- Time spent if using time-based coding (with notation that >50% was counseling/coordination)