CPT code 99202

99202 CPT code is used to bill a specific type of new patient for office visits and is mainly used by medical professionals and psychiatrists. Navigating the complexities of billing and coding, such as using the 99202 CPT code, is essential for ensuring accurate reimbursement and effective management.

Summary

• 99202 CPT code is used for new patient office visits involving low-complexity medical decision-making or when the total time spent on the encounter date is 15–29 minutes. It’s important for providers to ensure the patient meets "new patient" criteria (no professional services in the past 3 years).
• Accurate, detailed documentation is crucial to justify billing with 99202. Key documentation elements include a chief complaint, brief history of present illness (HPI), low-complexity medical decision-making (MDM), and, when relevant, care coordination notes.
• Billing errors to avoid include upcoding (billing higher-complexity codes without meeting criteria), downcoding (underbilling when complexity/time supports a higher code), and misapplying new patient definitions, all of which can lead to reimbursement issues. Enrolling in an insurance billing course for therapists can help providers enhance their knowledge.
• When in doubt, match the service’s complexity and time to the correct code. CPT 99202 should only be used when both the visit complexity and documentation clearly fit low-complexity standards; otherwise, codes 99203–99205 may be more appropriate. By leveraging an EHR like TheraPlatform for efficient documentation and claim submission, therapists can tackle billing with ease.

In this guide, we’ll provide a detailed overview of the 99202 CPT code. Follow along for a definition of this code, details on documentation and billing requirements, low-complexity medical decision-making, and what to avoid when using it.

What is the 99202 CPT code?

The definition of CPT 99202 is an office or other outpatient visit for evaluating and managing a new patient, where the services provided are low-complexity.

This code is used for a basic new patient visit that still requires medical decision-making and care coordination.

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New patient designation

In CPT terminology (according to the American Medical Association (AMA)), “new patient” refers to a patient who has not received any professional services from the provider or another provider in the same specialty and group within the past three years.

Low complexity

CPT 99202 should refer to an initial encounter in which the healthcare professional comprehensively understands the patient’s concerns.

In this appointment, the provider typically reviews the patient’s relevant history and formulates an initial treatment plan based on low-complexity decision-making.

Time requirement for the 99202 CPT code

Therapists can use CPT 99202 based on medical decision-making (MDM) or the time spent on the encounter date. When following time-based billing, providers can use CPT 99202 when the total time spent is 15 to 29 minutes.

This time may include:

• A review of records
• Face-to-face time with the patient
• Electronic Health Record (EHR) documentation
• Placing referrals or ordering tests
• Communication with the patient’s family or with other providers involved in the patient’s care
• Discussing the results and treatment plan with the patient
• Performing clinical observations or assessments

Healthcare professionals should remember that time, along with the level of medical decision-making and the extent of the examination, are key factors in selecting and using the 99202 CPT code.

Documentation requirements for the 99202 CPT code

Thorough, accurate documentation is essential when billing the 99202 CPT code. The provider’s clinical notes must reflect the level of service provided, and clinical documentation serves as justification for using this CPT code.

Key components of the documentation for a CPT 99202 service include:

Patient history

• History of Present Illness (HPI): Therapists should document the patient’s relevant history. A brief description of pertinent past or family history is sufficient for a low-complexity medical decision-making visit.
• Chief complaint: Documentation should clearly state the primary reason for the patient’s visit.

Low complexity medical decision-making (MDM)

The MDM must reflect low complexity for CPT 99202, including:

• Diagnosis: This will typically consist of one or two minor diagnoses
• Brief data review: A limited review of records or outside tests may be included in the documentation.

Coordination of care notes

If applicable, notes regarding time spent coordinating care with other healthcare professionals should be included.

This includes communication with the primary care physician, psychiatrist, or others working with the patient. This is not a required component of CPT 99202 documentation, but can be relevant in some cases.

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Billing tips for therapists

When to use vs. higher-level codes (99203-99205)

Therapists must understand when it is appropriate to use CPT 99202 in billing. This CPT code should be differentiated from higher-level new patient codes (99203-99205).

Here are some general guidelines for the correct application of these codes:

Key tips for using the 99202 CPT code

When using the 99202 CPT code, there are a few key tips for providers to keep in mind:

• Ensure complexity is accurately reflected. CPT 99202 should only be used when low-complexity decision-making is used. Also, remember the complexity of the patient’s presentation, clinical observations, and history.
• Focus on medical necessity. Documentation should clearly reflect the medical necessity of the services provided.
• Keep time in mind. This code can be used either when the time spent is 15-29 minutes or when low-complexity medical decision-making is used.
• Be clear on “new patient” criteria. Confirm that the individual meets the requirements of being considered a “new patient.”

Challenges and what to avoid with the 99202 CPT code

• Insufficient documentation. Billing issues like denials and delays can occur when detailed and sufficient documentation is lacking to support the chosen CPT code. Notes should be written clearly and provide accurate information in crucial areas such as history, observations, and low-complexity medical decision-making.
• Upcoding. Do not bill higher-level codes such as 99203 when the service does not meet the required criteria.
• Downcoding. Under-reimbursement may result from billing 99202 when the complexity and time involved in the appointment warrant a higher-level code.
• Incorrect understanding of “new patient” criteria. Misinterpreting “new patient” criteria can result in billing issues and should be avoided.

CPT code 99202, used when billing low-complexity new patient evaluations, is important for providers to understand.

Therapists should ensure that requirements such as time (15-29 minutes), low-complexity medical decision-making, and accurate documentation are followed when applying this code.

How EHR and practice management software can save you time with insurance billing for therapists

EHRs with integrated billing software and clearing houses, such as TheraPlatform, offer therapists significant advantages in creating an efficient insurance billing process. The key is minimizing the amount of time dedicated to developing, sending, and tracking medical claims through features such as automation and batching. 

What are automation and batching?

• Automation refers to setting up software to perform tasks with limited human interaction.
• Batching or performing administrative tasks in blocks of time at once allows you to perform a task from a single entry point with less clicking.

Which billing and medical claim tasks can be automated and batched through billing software?

• Invoices: Create multiple invoices for multiple clients with a click or two of a button or set up auto-invoice creation, and the software will automatically create invoices for you at the preferred time. You can even have the system automatically send invoices to your clients.
• Credit card processing: Charge multiple clients with a click of a button or set up auto credit card billing, and the billing software will automatically charge the card (easier than swiping!)
• Email payment reminders: Never manually send another reminder email for payment again, or skip this altogether by enabling auto credit card charges.  
• Automated claim creation and submission: Batch multiple claims with one button click or turn auto claim creation and submission on. 
• Live claim validation: The system reviews each claim to catch any human errors before submission, saving you time and reducing rejected claims. 
• Automated payment posting: Streamline posting procedures for paid medical claims with ERA. When insurance offers ERA, all their payments will post automatically on TheraPlatform's EHR.
• Tracking: Track payment and profits, including aging invoices, overdue invoices, transactions, billed services, service providers 

Utilizing billing software integrated with an EHR and practice management software can make storing and sharing billing and insurance easy and save providers time when it comes to insurance billing for therapists.

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Resources

Theraplatform is an all-in-one EHR, practice management and teletherapy solution that allows you to focus more on patient care. With a 30-day free trial, you have the opportunity to experience Theraplatform for yourself with no credit card required. Cancel anytime. They also support different industries, including mental and behavioral health therapists in group practices and solo practices.

References

Burks, K., Shields, J., Evans, J., Plumley, J., Gerlach, J., & Flesher, S. (2022). A systematic review of outpatient billing practices. SAGE Open Medicine, 10, 20503121221099021. DOI: https://doi.org/10.1177/20503121221099021.

Romans, B., Nguyen, E., Biddle, M., Paul, A., Rosko, Z., Minaei, A., ... & Robinson, R. F. (2022). Billing and coding: disparities in healthcare provider training. Journal of Allied Health, 51(1), 43-46. DOI: https://www.ingentaconnect.com/content/asahp/jah/2022/00000051/00000001/art00009

Schwartz, A. L., Chen, Y., Jagmin, C. L., Verbrugge, D. J., Brennan, T. A., Groeneveld, P. W., & Newhouse, J. P. (2022). Coverage Denials: Government And Private Insurer Policies For Medical Necessity In Medicare: Study examines medical necessity coverage denials in Medicare and private insurers. Health Affairs, 41(1), 120-128. https://doi.org/10.1377/hlthaff.2021.01054