office visit CPT code - 99201 - 99205 - does require referring physician ?


CPT code 99201: Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 10 minutes face-to-face with the patient and/or family.

The 99201 code has more specific requirements than 99211 when it comes to elements of the history, purgative and medical decision making. In addition, 99201 is not to be used for nursing visits, as the physician needs to see the patient and establish a care plan before nurses' visits can be billed.


Time Period for CPT 99201 - 99205

CPT 99201 - 10 Minute
CPT 99202 - 20 Minute
CPT 99203 - 30 Minute
CPT 99204 - 45 Munute
CPT 99205 - 60 Minute

Billing with Preventive code

A preventive E/M visit with a problem-oriented service. Use a CPT preventive medicine service code (99381-99397) plus the appropriate E/M code (99201-99215) with modifier 25 attached to show that the services were significant and separate. Link the appropriate ICD-9 code(s) to each CPT code to help distinguish the services. Note that not all payers will reimburse for both preventive and problem-oriented services on the same date

The preventive E/M visit with a problem-oriented service When a patient comes into the office for a routine preventive examination, and has significant new complaints (e.g., chest pain or irregular bleeding) and, in some instances, a new or established chronic condition (e.g., hypertension or type-II diabetes), the visit becomes a  combination of preventive and problem-oriented care. As long as the problem-oriented service is clearly documented and distinct from the documentation of the preventive service, CPT suggests submitting a preventive medicine services code (99381-99397) for the routine exam, and the appropriate office visit code (99201-99215) with modifier –25,” significant, separately identifiable [E/M] service by the same physician on the same day of the procedure or other service," attached to the problem-oriented service. It's also especially important to link the appropriate ICD-9 code to the applicable CPT code in these cases to help distinguish between
preventive and problem-oriented services

CPT Code 99205 OFFICE OUTPATIENT NEW 60 MINUTES

Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision making of high complexity.

Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity.

 Physicians typically spend 60 minutes face-to-face with the patient and/or family.

Centers of Medicare and Medicaid Services (CMS) in our time identify the current procedural terminology as the level one of the healthcare common procedure coding system. The cpt code 99201 denotes problem focused in the history and physical exam sections of records of new office patients.

In general, the CPT codes range from 99201 to 99499 indicates evaluation and management.  The current procedural terminology code 99201 to 99215 denotes office or other outpatient services. You have to know about these codes when you have geared up for enhancing your proficiency in the current procedural terminology day after day.

The cpt code used for indicating the level 1 new patient office visit is 99201.  As the lowest level care for every new patient in the medical office, 99201 assists all healthcare professionals and people who work in the medical sector to know about the new patient office visit directly. 

The overall health problems of these patients are minor or self-limited. The most competitive price of treatment for patients who have 99201 for new office visit nowadays attracts people who think about the cost of the initial healthcare treatment.  

There are three important elements in the documentation associated with the level 1 new patient office visit 99201. These elements are problem focused history, problem focused exam and straightforward medical decision making.  If there is current procedural terminology based on time, then patients consult with medical professionals face to face and use this appropriate documentation.
Beginners to CPT these days seek the definition of new patient. They have to keep in mind that a new patient is one who has not received any healthcare treatment from any medical professional within the past three years. An established patient is a patient who has received professional medical services from physicians in the same group within the past three years.    People who focus on the history, exam, medical decision making and typical face to face time in the new patient office visit level 1 record can get the complete details about healthcare issues of the patient.    

Q: How should the initial OB visit be reported?


A: Per ACOG guidelines, if the OB record is not initiated, then the office place of service visit should be reported separately by using the appropriate E/M CPT code (99201-99215, 99241-99245 and 99341-99350) and ICD-9-CM diagnosis code of V72.42 to be used on or before date of service September 30, 2015 or ICD-10-CM diagnosis code of Z32.01 to be used on or after date of service October 01, 2015. If the OB record is initiated during the confirmatory visit, then the confirmatory visit becomes part of the global OB package and is not reported separately.

Evaluation and Management Service Codes - General (Codes 99201 - 99499)


A. Use of CPT Codes Advise physicians to use CPT codes (level 1 of HCPCS) to code physician services, including evaluation and management services. Medicare will pay for E/M services for specific non-physician practitioners (i.e., nurse practitioner (NP), clinical nurse specialist (CNS) and certified nurse midwife (CNM)) whose Medicare benefit permits them to bill these services. A physician assistant (PA) may also provide a physician service, however, the physician collaboration and general supervision rules as well as all billing rules apply to all the above non-physician practitioners. The service provided must be medically necessary and the service must be within the scope of practice for a non-physician practitioner in the State in which he/she practices. Do not pay for CPT evaluation and management codes billed by physical therapists in independent practice or by occupational therapists in independent practice.

Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported. The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record.

B. Selection of Level Of Evaluation and Management Service

Instruct physicians to select the code for the service based upon the content of the service. The duration of the visit is an ancillary factor and does not control the level of the service to be billed unless more than 50 percent of the face-to-face time (for non-inpatient services) or more than 50 percent of the floor time (for inpatient services) is spent providing counseling or coordination of care as described in subsection C. Any physician or non-physician practitioner (NPP) authorized to bill Medicare services will be paid by the carrier at the appropriate physician fee schedule amount based on the rendering UPIN/PIN.

"Incident to" Medicare Part B payment policy is applicable for office visits when the requirements for "incident to" are met.

CPT code 99202: Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 20 minutes face-to-face with the patient and/or family.

CPT code 99203: Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; Medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. Physicians typically spend 30 minutes face-to-face with the patient and/or family.

CPT code 99204: Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 45 minutes face-to-face with the patient and/or family.

CPT code 99205: Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 60 minutes face-to-face with the patient and/or family.


Coding Question: Is it required by Medicare and Medicaid to have a referring physician in order to be able to bill for a new patient evaluation? If so, what should one do if the patient self refers himself/herself to you because of reputation/friend etc.?

Coding Response: 
The CMS definition for a new patient states that, “such a patient would be regarded as a new patient, a patient who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice within the last three years.” Therefore, any patient presenting him/herself to you would be regarded as a new patient. Effective January 1, 2010, CMS has eliminated payment for the office or other outpatient consultation codes 99241- 99245. The office and other outpatient visit codes for new patients (99201- 99205) are still recognized for reimbursement by CMS and may be used to report any new patient being seen in your practice. As a result of these changes, there is no distinction between a patient who is referred by a physician or one who is self referred; for Medicare they are both considered a new patient.  The E/M codes that can be used are CPT codes 99201 – 99205.




CPT code 99241: Office consultation for a new or established patient, which requires these 3 components:  a problem focused history, a problem focused examination, and straightforward medical decision making.

CPT code 99242: Office consultation for a new or established patient, which requires these 3 components:  an expanded problem focused history, an expanded problem focused examination, and straightforward medical decision making.

CPT code 99243: Office consultation for a new or established patient, which requires these 3 components:  a detailed history, a detailed examination, and medical decision making of low complexity.

CPT code 99244: Office consultation for a new or established patient, which requires these 3 components:  a comprehensive history, a comprehensive examination, and medical decision making of moderate complexity.

CPT code 99245: Office consultation for a new or established patient, which requires these 3 components:  a comprehensive history, a comprehensive examination, and medical decision making of high complexity.

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