New Patient Office or Other Outpatient Visits: Overview of Coverage and Documentation Requirements

Published 03/23/2018

This Comparative Billing Report (CBR) focuses on providers who have submitted claims for New Patient Office or other Outpatient Visit Evaluation and Management (E/M) Services (CPT codes 99201-99205). CBR information is one of the many tools used to assist individual providers to become proactive in addressing potential billing issues and performing internal audits to ensure compliance with Medicare coverage guidelines.

For your personalized eCBR results on New Patient Visit (E/M) Services (CPT codes 99201-99205) log into our eServices portal. 

Overview of CPT Codes 99201-99205
New Patient: An individual who did not receive professional services from a physician/non-physician practitioner (NPP) or another physician of the same specialty who belongs to the same group practice within the previous three years.

Key components in billing E/M CPT codes 99201-99205, are:

  1. History
  2. Examination
  3. Medical Decision Making

Description and Documentation Requirements for CPT Codes 99201-99205

CPT Code
Description
Documentation Requirements
99201
  • Typically 10 minutes
  • Problem focused history
  • Problem focused exam
  • Based on straightforward medical decision making
  • Minimal number of diagnoses or management options
  • Amount and/or complexity of data to be reviewed is none or minimal
  • Minimal risk of significant complications, morbidity and/or mortality
99202
  • Typically 20 minutes
  • Expanded Problem focused history
  • Expanded Problem focused exam
  • Based on straightforward medical decision making
  • Minimal number of diagnoses or management options
  • Amount and/or complexity of data to be reviewed is none or minimal
  • Minimal risk of significant complications, morbidity and/or mortality
99203
  • Typically 30 minutes
  • Detailed history
  • Detailed Examination
  • Based on low complexity medical decision making
  • Limited number of diagnoses or management options
  • Amount and/or complexity of data to be reviewed is limited
  • Low risk of significant complications, morbidity and/or mortality
99204
  • Typically 45 minutes
  • Comprehensive history
  • Comprehensive Examination
  • Based on moderate complexity medical decision making
  • Multiple number of diagnosis or management options
  • Amount and/or complexity of data to be reviewed is moderate
  • Moderate risk of significant complications, morbidity and/or mortality
99205
  • Typically 60 minutes
  • Comprehensive history
  • Comprehensive Examination
  • ·Based on high complexity medical decision making
  • Extensive number of diagnosis or management options
  • Amount and /or complexity of data to be reviewed is extensive
  • High risk of significant complications, morbidity and/or mortality

Methods:
The metrics reviewed in this CBR are the proportion of billing for each HCPCS code in the E/M grouping with comparisons to peers within the nationwide RRB SMAC Jurisdiction. This report is an analysis of Medicare Part B claims extracted from the Palmetto GBA data warehouse. The analysis shows the portions of your claims for CPT codes 99201-99205 at levels compared to your peers in the RRB Specialty MAC.

Example of eCBR Results from eServices:

Example of New Patient Office or other Outpatient Visit Evaluation and Management (E/M) Services Results

The RRB SMAC’s Provider Outreach and Education (POE), team has developed a web-based training (WBT) tool to address the issues pertinent to CPT codes 99201-99205. Your practice is encouraged to view our WBT using the links provided within our Educational Resources of this eCBR.

Please be aware that the information contained within this CBR is not intended to be punitive or an indication of fraud. Rather, it is intended to be proactive communication that will assist you in identifying potential billing issues and help you with performing a self-audit of your conformity with Medicare guidelines.

For more information about this or other eCBRs, please call our Provider Contact Center at 888-355-9165, and select Option 5. Customer Service Representatives are available Monday through Friday, from 8:30 a.m. - 4:30 p.m. in all time zones with the exception of Pacific Time. This service is available from 8:30 a.m. - 4 p.m. PT.

Educational Resources: