What is the recommended billing level for a 63-year-old patient new to establish care with private insurance?

Billing Level for New Patient Establishment Visit

For a 63-year-old patient establishing care with private insurance, bill based on the complexity of medical decision-making or total time spent, using CPT codes 99202-99205, with the specific level determined by either the complexity of problems addressed or total encounter time under the 2021 E/M guidelines. 1

Billing Framework Under 2021 Guidelines

The 2021 American Medical Association E/M guideline changes fundamentally altered how new patient visits are coded, eliminating the requirement to document physical examination findings to support coding levels 1. This change specifically facilitates more accurate billing that reflects the true complexity of care delivered 1.

Two Pathways for Level Selection

You can select the visit level using either:

• Medical Decision Making (MDM) complexity: Based on the number and complexity of problems addressed, amount and complexity of data reviewed, and risk of complications 1
• Total time: Including face-to-face time plus time spent on activities related to the encounter on the date of service (chart review, ordering tests, care coordination, documentation) 1

Specific CPT Codes for New Patients

For this 63-year-old establishing care, use these codes 1:

• 99202: Straightforward MDM or 15-29 minutes total time
• 99203: Low complexity MDM or 30-44 minutes total time
• 99204: Moderate complexity MDM or 45-59 minutes total time
• 99205: High complexity MDM or 60-74 minutes total time

Expected Billing Pattern for Establishment Visits

Most new patient establishment visits for adults in this age group will appropriately fall into 99203 or 99204 levels 2. Following the 2021 guideline implementation, there was a 2.2% relative increase in level 4 visits (99204 equivalent for new patients) and a 22.6% relative increase in level 5 visits, reflecting more accurate capture of visit complexity 2.

For a 63-year-old establishing care, you will typically address:

• Multiple chronic conditions common in this age group (hypertension, diabetes, hyperlipidemia) 1
• Medication reconciliation and review 1
• Preventive care planning and cancer screening discussions 1
• Assessment of functional status and fall risk 1
• Review of prior medical records and coordination with other providers 1

This complexity typically supports a 99204 level (moderate complexity MDM or 45-59 minutes total time) 1.

Documentation Requirements

Under the 2021 guidelines, you must document 1:

• If billing by time: The total time spent on the date of service (not just face-to-face time)
• If billing by MDM: The problems addressed, data reviewed/ordered, and risk assessment
• The patient's location (for telehealth visits, include Place of Service code and modifier 95) 1

Critical pitfall to avoid: Do not continue documenting extensive physical examination findings solely to justify billing levels—this is no longer required and contributes to unnecessary documentation burden 1, 2.

Private Insurance Considerations

For private insurance 1:

• Use the same CPT codes (99202-99205) as for Medicare
• Include appropriate Place of Service code (office = 11)
• No telehealth modifiers needed for in-person visits
• Charges typically range from $24 to $108 for establishment visits, though this varies widely by region and complexity 3

Time Documentation Best Practices

If billing by time, document the total time spent, including 1:

• Pre-visit chart review
• Face-to-face encounter time
• Ordering and reviewing diagnostic tests
• Care coordination with other providers
• Documentation
• Patient education materials preparation

Studies show that despite the 2021 guideline changes intended to reduce documentation burden, note length and EHR time have not meaningfully decreased 2. Focus on documenting what matters for patient care and billing justification, not excessive narrative.

Geriatric-Specific Considerations

For this 63-year-old patient, consider that 1:

• Assessment of comorbidities (≥3 conditions warrants specific documentation) 1
• Functional status screening 1
• Cognitive screening if indicated 1
• Fall risk assessment 1
• Medication review for polypharmacy 1

These assessments add complexity that supports higher-level billing (99204 or 99205) and should be documented to reflect the true complexity of care 4.

Revenue Optimization

Accurate coding to reflect complexity of care can increase revenue by approximately $23.40 per encounter when moving from level 3 to level 4 billing 4. For an academic or complex patient population, ensuring documentation captures the true complexity delivered can increase revenue by $233,989 per 10,000 encounters 4.