CPT Code 99202: Billing, Documentation and Reimbursement Guide [2026]

Medicare data from 2023 shows CPT code 99202 appeared on more than 12 million claims. CMS audit findings reveal approximately 23% of those claims contained documentation or coding errors. That's a staggering volume of preventable revenue loss hitting practices of every size.

CPT code 99202 is an evaluation and management code for a new patient office or other outpatient visit requiring straightforward medical decision making or 15 to 29 minutes of total provider time on the encounter date. Getting any part of this wrong, whether it's the patient status, time threshold, or MDM level, puts your reimbursement at risk.

This guide covers every element of the 99202 CPT code for 2026: Medicare reimbursement rates, the dual conversion factor update, G2211 interaction rules, modifier guidance, straightforward MDM documentation standards, and denial prevention strategies. It's built for medical coders, billers, physicians, nurse practitioners, physician assistants, and practice administrators who need clear, current billing answers.

MedSole RCM is a full-service revenue cycle management company that helps providers bill E/M codes accurately and collect what they've earned. Everything in this guide reflects the compliance standards we apply across the practices we serve.

What Is CPT Code 99202?

CPT code 99202 is an evaluation and management (E/M) billing code used for an office or other outpatient visit involving a new patient. It requires either straightforward medical decision making or 15 to 29 minutes of total provider time on the encounter date. That's the core CPT code 99202 definition, and it drives how you document, code, and bill these encounters.

The code belongs to the Current Procedural Terminology system maintained by the American Medical Association (AMA). It sits within the Office or Other Outpatient Services code family (99202 to 99215) and is designated exclusively for new patients.

CMS adopted this classification for Medicare reimbursement under the evaluation and management framework, and nearly every commercial payer follows the same structure. You can verify the 99202 CPT code specifics through the AAPC codify database.

Key Facts at a Glance

What is CPT code 99202 in practical terms? It's the code you report when a new patient presents with a straightforward clinical issue and the visit doesn't require complex workup, extensive testing, or significant resources.

Providers select CPT code 99202 through one of two pathways. The 2021 evaluation and management guideline overhaul by the AMA and CMS established this dual-pathway framework:

• Medical decision making pathway: The provider documents straightforward MDM, meeting the required threshold in at least two of three elements: problem complexity, data reviewed, and risk level.

• Total time pathway: The provider records 15 to 29 minutes of total time on the encounter date, covering both face-to-face and non-face-to-face work by the billing provider.

Only one pathway needs to be met and documented. The 99202 CPT code applies across primary care, mental health, chiropractic, dermatology, and other specialties. There's no restriction on which office visit CPT code a new patient encounter uses at this level, as long as documentation supports the selection.

99202 CPT Code Description

The official 99202 CPT code description, as published in the AMA CPT Professional Edition, reads:

"Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 15 minutes must be met or exceeded."

Source: American Medical Association, CPT Professional Edition

In plain language, this CPT code 99202 description means the provider conducts a clinically relevant assessment and makes simple clinical decisions. No exhaustive workup is required. The documentation needs to reflect what's medically appropriate for the presenting complaint, not a comprehensive head-to-toe evaluation.

Here's some important context on how this 99202 CPT code description reached its current form. Before January 1, 2021, codes 99202 through 99205 required three distinct key components: history, examination, and medical decision making. Each component had its own levels that had to be met independently.

The 2021 revision eliminated those rigid requirements and introduced the current framework where providers choose between MDM level or total time. That change simplified code selection significantly for most practices.

On that same date, CMS and the AMA deleted CPT code 99201 because it shared the same straightforward MDM level as 99202. That redundancy made 99201 unnecessary, and 99202 became the lowest-level new patient evaluation and management code for office or outpatient visits.

Is CPT Code 99202 Still Valid in 2026?

Yes. CPT code 99202 is a valid, active code in 2026. The 2021 deletion of 99201 didn't affect 99202 in any way. Its descriptor, requirements, and reimbursement status remain completely unchanged. CMS continues to recognize it for Medicare payment, and no modifications are scheduled for upcoming code cycles.

Who Is a New Patient for CPT Code 99202?

The CMS and AMA define a new patient as someone who hasn't received any face-to-face professional services from the same physician, or another physician of the same specialty and subspecialty within the same group practice, within the previous three years.

That three-year window is everything. Get it wrong, and you're looking at denied claims and potential audit flags.

"Professional services" means face-to-face encounters billed under a specific CPT code. Phone calls don't count. Patient portal messages don't count. Scheduling interactions, prescription refills, and administrative contacts don't reset the clock either.

Here's where it gets tricky with group practices. In a multi-specialty group, a patient can be classified as new to one specialty even if they've seen a different specialty within the same organization. A patient who saw your group's cardiologist last month could still qualify as new to your group's dermatologist.

Single-specialty groups work differently. If any provider in the group saw that patient within three years, the patient is established for every provider in the group. No exceptions.

Let's say a patient last visited your practice's internal medicine provider in January 2023. In March 2026, they schedule a new appointment with the same provider. Because more than three years have passed, this patient qualifies as a new patient under CPT guidelines and you can bill CPT code 99202 if the visit meets the MDM or time criteria.

Misclassifying an established patient as new is one of the fastest ways to trigger a 99202 claim denial. Payers catch it quickly because they can cross-reference their own claims history. Before assigning any CPT code for new patient visits, verify patient status through your EHR records or past claims data. A 30-second check prevents a much bigger headache down the line.

CPT Code 99202 Time Requirements: What Counts in 2026

When selecting CPT code 99202 based on time, the provider must spend at least 15 minutes but less than 30 minutes of total time on the date of the encounter. Hit 30 minutes, and you're looking at 99203 territory. Under 15 minutes, don't bill 99202 at all.

The AMA E/M guidelines define "total time" as both face-to-face and non-face-to-face activities personally performed by the billing provider on the same calendar date. That distinction matters more than most people realize. It's not just the time spent in the room with the patient.

What Activities Count Toward Total Time?

These are the activities the billing provider can include in the 99202 time requirement calculation:

• Reviewing patient records, test results, and imaging before or after the visit

• Performing a medically appropriate history and/or examination

• Counseling and educating the patient, family, or caregiver

• Ordering medications, tests, or procedures

• Documenting clinical information in the EHR

• Communicating with other healthcare professionals about the patient (when not separately billed)

• Independently interpreting results and communicating findings (when not separately billed)

What Does Not Count Toward Time?

Not everything that happens during an encounter day counts toward your 99202 time. Keep these out of your calculation:

• Time spent by nurses, medical assistants, or other clinical staff

• Travel time

• Time for services billed separately under their own CPT codes

• General administrative or scheduling tasks

• General teaching not related to the specific patient

How to Document Time for CPT Code 99202

Here's something most practices don't know: the AMA clarifies that providers aren't required to document time spent on each individual task. What you do need is the total time recorded with enough activity detail to survive an audit.

A compliant entry looks like this:

"Total clinician time on date of service: 22 minutes. Activities included reviewing outside records, face-to-face evaluation and examination, counseling patient on treatment plan, and documentation."

Compare that to what auditors actually see on a regular basis:

"Spent time with patient." [INSUFFICIENT: Vague, no total minutes, no activity description. Does not support time-based code selection.]

That second example won't hold up. It tells the auditor nothing verifiable about what the provider actually did or how long it took. When a payer questions your 99202 time, that note is all you have.

The table below shows how 99202 time fits within the full new patient E/M code range. If your documented time crosses into the next threshold and the clinical documentation supports it, bill the higher code.

What Is the Criteria for CPT Code 99202? MDM Requirements Explained

When selecting CPT code 99202 based on medical decision making rather than time, the MDM must be classified as straightforward. The AMA CPT guidelines define MDM using three elements, and the provider must meet or exceed the straightforward threshold in at least two of the three to support this code. That's the "2 of 3" rule, and it's the foundation of the CPT code 99202 requirements under the MDM pathway.

The Three MDM Elements for Straightforward Complexity

The CMS MLN E/M framework breaks medical decision making into three distinct elements. Here's what straightforward looks like for each one:

Two of these three elements need to land at the straightforward level. If one element is higher, that's fine as long as the other two hold at straightforward. The code still stands.

Practical MDM Assessment Example

Here's how straightforward MDM plays out in a real new patient encounter:

A new patient presents with mild seasonal allergies and no prior treatment. The provider takes a focused history, examines the nasal passages and throat, and recommends an over-the-counter antihistamine. No lab work is ordered.

Problem: One self-limited condition (seasonal allergies). Straightforward.
Data: None reviewed. Straightforward.
Risk: OTC medication only, no prescription required. Minimal risk. Straightforward.

All three elements land at straightforward. This visit supports 99202 under the MDM pathway.

Know where the line is, though. If that same patient also needs a prescription antibiotic, the risk element moves to low because prescription drug management carries more complexity than an OTC recommendation. One prescription can push you from 99202 into 99203.

The same applies when a visit involves ordering diagnostic imaging, managing two or more self-limited problems at once, or addressing a stable chronic illness for the first time. Any of those scenarios likely takes the MDM above straightforward. When that happens, 99203 or higher is the appropriate code, not 99202.

How to Select CPT Code 99202: Time-Based vs MDM-Based Coding

Since the 2021 evaluation and management guideline overhaul by the AMA and CMS, providers can select CPT 99202 based on either total time or medical decision making complexity. You pick whichever method best reflects the encounter. Only one method needs to be documented.

That's a point worth emphasizing. If you select by MDM, you don't need to record 99202 time. If you select by time, the MDM level doesn't need to match. The two pathways are independent of each other.

When to Use Time

Time-based selection works best when the encounter involves significant non-face-to-face work that straightforward MDM alone wouldn't capture. Think about visits where you spent 20 minutes reviewing outside records before the patient even walked in, or where lengthy care coordination calls ate up most of the encounter.

It's also useful when the clinical decision making is simple but the visit still took real effort. A focused allergy evaluation with 25 minutes of total provider work qualifies for 99202 by time, even if the MDM feels almost too basic to justify a code.

When to Use MDM

MDM-based selection makes more sense for quick, efficient visits where the clinical reasoning clearly supports straightforward MDM. If a provider sees a new patient for a minor complaint, makes a clear assessment, and wraps up in 12 minutes, the visit doesn't meet the 15-minute time floor. But if the MDM hits straightforward, you can still bill 99202.

This approach also cuts down on administrative burden. Documenting total time with activity descriptions takes effort. When the MDM speaks for itself, let it carry the code.

For most practices, picking one method as the default and training all providers to document accordingly reduces compliance risk. Consistency matters more than perfection here.

CPT Code 99202 Documentation Requirements and Compliance Checklist

Accurate documentation is the single most important factor in successful 99202 CPT code billing. Vague clinical notes are the leading cause of claim denials and audit findings for this code. Under the current E/M framework, your documentation must support whichever selection method the provider chose, whether that's time or medical decision making.

Documentation Checklist for 99202

Every 99202 encounter note should address these CPT code 99202 requirements before the claim goes out:

Sample Documentation for a 99202 Visit

Here's what a clean, audit-ready 99202 note looks like in practice:

Patient: [Name]
Date of Service: March 15, 2026
Patient Status: New patient

Chief Complaint: Mild sore throat for three days.

History: No fever, no difficulty swallowing. Non-smoker. No current medications. No known allergies.

Examination: Oropharynx mildly erythematous. No tonsillar exudate. Cervical lymph nodes non-tender. Vitals within normal limits.

Assessment: Acute pharyngitis (ICD-10: J02.9).

Plan: Supportive care. OTC ibuprofen as needed for discomfort. Follow up if symptoms persist beyond seven days or worsen.

MDM: Straightforward. One self-limited problem addressed. No data reviewed. Minimal risk (OTC medication only).

Code Selection Basis: MDM.

Compare that with what we see too often in denial management reviews: chief complaints like "not feeling well," missing MDM justification, unspecified time entries, or no confirmation of new patient status. Any of those gaps gives a payer reason to deny or a reviewer reason to downcode.

Documenting every E/M encounter to compliance standards takes real time and attention. Practices that struggle with documentation-driven denials often benefit from working with a dedicated medical billing partner. MedSole RCM provides outsourced medical billing services at 2.99% of collections, with built-in documentation review and coding accuracy checks that reduce denial rates and accelerate reimbursement.

Who Can Bill CPT Code 99202?

CPT code 99202 can be billed by physicians (MD and DO), nurse practitioners (NP), and physician assistants (PA). Some payers also allow clinical psychologists to bill E/M codes within their scope of practice.

Here's the full breakdown by provider type:

One rule matters above all others here: only time personally spent by the billing provider counts toward the 15-minute threshold. Your nurse spent 10 minutes rooming the patient and taking vitals? That's important clinical work, but none of it applies to the time calculation for who can bill CPT code 99202.

Incident-To Billing and 99202

Incident-to billing lets services performed by non-physician practitioners under direct physician supervision get billed under the physician's NPI. It's a common arrangement for new patient visits, but here's the catch: incident-to applies only to established patients.

CPT code 99202 is a new patient code. It generally can't be billed under incident-to arrangements. The encounter needs to go out under the NPI of the provider who actually performed the service.

Proper credentialing with each payer is a prerequisite for billing any E/M code. Providers who aren't enrolled with a payer can't submit claims under their own NPI, which means the practice can't get paid for the visit at all.

Need to get providers credentialed with payers quickly? MedSole RCM offers provider enrollment and credentialing services at $99 per payer, among the fastest and most affordable in the industry.

CPT Code 99202 Reimbursement Rates and Cost (2026)

The 2026 Medicare national non-facility reimbursement rate for 99202 CPT code reimbursement is approximately $72, based on the CMS Physician Fee Schedule. The facility rate is approximately $46. Actual reimbursement varies by geographic locality, ranging from roughly $63 to $88 across Medicare Administrative Contractor regions.

Medicare Reimbursement (2026 Rates)

The gap between those two numbers comes down to practice expense. In an office setting, the provider absorbs overhead costs like rent, equipment, and staff. Medicare compensates for that through higher practice expense RVUs. Hospital outpatient settings shift those costs to the facility, so the provider's reimbursement drops.

CMS finalized a major payment update for 2026: two separate conversion factors. Qualifying APM participants (QPs) receive a conversion factor of $33.57, while non-QP physicians get $33.40. This is a statutory change under MACRA that affects the 99202 CPT code cost and every other E/M code on the fee schedule.

The payment formula works like this: Payment = [(Work RVU x Work GPCI) + (PE RVU x PE GPCI) + (MP RVU x MP GPCI)] x Conversion Factor.

Commercial Payer Average Reimbursement

Commercial rates run higher than Medicare but vary significantly by contract, specialty, and region. Here's what 99202 CPT code reimbursement typically looks like across major payers:

These numbers are averages. Your actual contracted rate could be higher or lower depending on your fee schedule negotiations.

2026 CMS Policy Changes Affecting 99202 Payment

Three policy changes from the 2026 CMS final rule directly affect how much practices collect on this code:

1. Efficiency adjustment exemption. CMS applied a -2.5% efficiency adjustment to work RVUs for nearly all non-time-based services. E/M codes including 99202 are exempt from this cut because they're classified as time-based services. That's good news for any practice billing new patient visits.

2. Practice expense shift. CMS changed its indirect PE RVU methodology: non-facility settings gained roughly +4%, while facility settings dropped about -7%. Office-based practices billing 99202 may see a slight payment bump. Hospital-employed providers will likely see a reduction.

3. Dual conversion factor. Practices need to verify which conversion factor applies to their billing entity. The $0.17 difference between QP and non-QP rates might seem small, but across thousands of claims per year, it adds up.

Maximizing reimbursement for E/M codes takes more than accurate coding. It demands clean claim submission, timely follow-up, and strategic denial management. MedSole RCM's revenue cycle management solutions and outsourced medical billing services at 2.99% of collections help practices capture every dollar they earn.

What Is the Difference Between 99202 and 99203?

The primary difference between 99202 vs 99203 comes down to medical decision making complexity and time. CPT 99202 requires straightforward MDM and covers visits of 15 to 29 minutes, while 99203 requires low complexity MDM and covers visits of 30 to 44 minutes.

That distinction sounds simple on paper. In practice, it's the most common coding boundary question we see from providers billing new patient visits.

Time Comparison

The 99202 vs 99203 time split is clean. If your total provider time on the date of service falls between 15 and 29 minutes, you're in 99202 CPT code territory. Once you hit 30 minutes, the visit crosses into 99203, provided the documentation supports it.

Remember: "total time" means everything the billing provider personally did that day for the patient. Chart review before the visit, the face-to-face encounter, care coordination calls, and documentation afterward all count.

Medical Decision Making Comparison

This is where the 99202 vs 99203 distinction gets practical. The MDM thresholds differ across all three elements:

Here's how the boundary plays out clinically:

A new patient comes in with a simple sore throat. No testing needed. The provider recommends rest, fluids, and OTC lozenges. That's 99202: one self-limited problem, no data review, minimal risk.

Now take the same patient, but add a history of recurrent strep. The provider orders a rapid strep test, reviews the result, and prescribes amoxicillin. That's 99203: increased data review (ordering and reviewing a diagnostic test) and higher risk (prescription drug management).

The difference between those two scenarios is one test and one prescription. But it moves the medical decision making from straightforward to low complexity.

Reimbursement Impact

Under the 2026 Medicare fee schedule, 99202 reimburses approximately $72 and 99203 reimburses approximately $107. That's roughly a $35 difference per visit.

Sounds modest for a single encounter. But run the numbers over a year. A practice seeing 15 new patients per week that consistently undercodes 99203 visits as 99202 could forfeit more than $27,000 annually in legitimate reimbursement. That's not a coding technicality. It's a revenue cycle problem that compounds every week the pattern continues.

99202 vs 99212: New Patient vs Established Patient

The 99202 CPT code is used for new patient evaluation and management visits while 99212 is used for established patient visits. Both codes require straightforward medical decision making, but they differ in patient status, time range, and reimbursement.

Here's the side-by-side breakdown for CPT code 99202 vs 99212:

Why does 99202 pay $20 more than 99212 when both require the same MDM level? It comes down to the work involved. New patient visits require the provider to build a baseline understanding of the patient's medical history, current medications, allergies, family history, and social context from scratch. That additional effort is reflected in higher RVU values and correspondingly higher payment.

The compliance risk here is real. Billing the 99202 CPT code for an established patient is a direct coding violation. Payers flag it quickly because they can cross-reference their own claims data. If a patient has a paid claim from your practice within the past three years, submitting 99202 will trigger a denial, a recoupment request, or both.

Always verify the three-year rule before assigning new patient status. It takes seconds and prevents costly corrections later.

What Is the Difference Between 99202 and 99213?

CPT 99202 is used for new patient visits with straightforward medical decision making, while 99213 is used for established patient visits with low complexity MDM. The codes differ in patient status, MDM level, and time range.

These two codes serve completely different patient populations, and mixing them up creates billing problems in both directions. Selecting 99202 for an established patient triggers a denial because payers verify patient status against their own claims history. Selecting 99213 for a new patient is equally wrong, even though the time ranges overlap.

The fix is straightforward. Build a verification step into your intake workflow that confirms patient status before the provider even walks into the room. Your front desk or scheduling team should flag whether someone is new or established at the point of booking, and the billing team should confirm it again before the claim goes out.

CPT Codes 99202 to 99205: Complete New Patient E/M Code Range

CPT 99202 is the lowest-level office visit CPT code for a new patient in the E/M code range of 99202 through 99205. Knowing where each code sits in that range helps providers avoid both undercoding and overcoding on every new patient encounter.

Here's the complete picture with 2026 Medicare rates:

Choosing the Right Code for Visit Complexity

Code selection should reflect the highest level of complexity your documentation supports. Don't default to a CPT code for new patient visits based on habit or visit type. Instead, follow this framework:

1. Confirm the patient qualifies as new (three-year rule)

2. Assess MDM complexity or document total provider time

3. Select the 99202 CPT code that matches, or whichever higher code your documentation justifies

One thing worth noting: CPT code 99201 was deleted effective January 1, 2021 because it shared the same straightforward MDM level as 99202. That made it redundant. For visits where total time falls below 15 minutes and MDM doesn't reach straightforward, the encounter may not qualify as a separately billable E/M service.

What about visits that run long? If a new patient encounter exceeds 74 minutes, report 99205 plus the prolonged services add-on code 99417 for each additional 15-minute increment beyond 74 minutes. That captures the full scope of work without overcoding the base visit.

99202 CPT Code RVU Breakdown and Payment Calculation (2026)

Understanding the relative value unit (RVU) structure behind CPT 99202 helps providers predict reimbursement and gives practice administrators real leverage during payer contract negotiations. The 99202 CPT code RVU determines Medicare payment when multiplied by the CMS conversion factor and adjusted for geographic location.

For a non-facility setting, the RVU components break down like this:

Facility-based services use a lower PE RVU of approximately 0.38 because the hospital absorbs overhead costs. That drops the total RVU to approximately 1.36 and cuts provider reimbursement to roughly $46. It's the main reason office-based billing for 99202 pays significantly more.

How Medicare Calculates 99202 Payment

Medicare applies this formula to convert 99202 CPT code RVU values into a dollar amount:

Payment = [(Work RVU x Work GPCI) + (PE RVU x PE GPCI) + (MP RVU x MP GPCI)] x Conversion Factor

The GPCI (Geographic Practice Cost Index) adjusts each RVU component for regional cost differences in labor, rent, and malpractice insurance. A provider in Manhattan has a higher GPCI than one in rural Kansas, which is why the same 99202 CPT code pays differently depending on location.

For 2026, two separate conversion factors apply: $33.57 for qualifying APM participants and $33.40 for non-QP physicians. This dual conversion factor system is a 2026 change that comes from statutory requirements under MACRA. Your billing entity determines which rate gets applied to your claims.

Using the national average GPCI of 1.0, the calculation works out to:

(0.93 + 0.85 + 0.05) x $33.40 = approximately $61.12

In higher-cost localities, GPCI adjustments push the total to $72 or even $88. That's why your actual Medicare payment won't match the baseline number exactly. Commercial payers typically reimburse at 110% to 150% of Medicare rates, which makes knowing your RVU breakdown a useful starting point when negotiating contracts.

What Modifier Is Used for 99202? Common Modifiers Explained

The most commonly used modifier with the 99202 CPT code is Modifier 25, which indicates a significant, separately identifiable E/M service performed on the same day as a procedure. For 99202 CPT code telehealth visits, Modifier 95 (synchronous audio and video) or Modifier 93 (audio-only) is required depending on how the service was delivered.

These are the modifiers you'll encounter most often with procedure code 99202:

Modifier 25 with CPT Code 99202

Modifier 25 is the most scrutinized modifier in E/M medical billing. Payers audit it aggressively. Misuse is one of the quickest ways to trigger a targeted chart review, so getting the documentation right matters more here than almost anywhere else in coding.

The AMA's guidance on CPT code 99202 modifier 25 is clear: different diagnoses aren't required to justify reporting both an E/M and a procedure on the same day. What matters is whether the E/M service was clinically distinct from the procedure itself.

CMS emphasizes that new patient status alone isn't sufficient to bill a separate E/M alongside a minor surgical procedure. Your CPT code 99202 modifier 25 documentation must demonstrate that the evaluation was significant and separately identifiable beyond the procedure's inherent pre-service, intra-service, and post-service work.

The E/M note should stand on its own with a distinct chief complaint, history, assessment, and plan separate from the procedure documentation. If an auditor can't tell where the E/M ends and the procedure begins, expect a denial.

Telehealth Modifiers (95 and 93)

CMS prefers Modifier 95 for synchronous audio and video telehealth services. Modifier 93 covers audio-only encounters when the patient can't access video. Both work with 99202 as long as the standard time and MDM requirements are met.

One thing to watch: not every payer follows the same modifier rules. Some commercial payers and Medicaid programs still require Modifier GT instead of 95. Always check individual payer requirements before submitting telehealth claims to avoid unnecessary rejections.

Other Situational Modifiers

Modifier 57 applies when the E/M visit results in a decision for major surgery with a 90-day global period. It's rarely relevant for 99202 since straightforward MDM visits don't typically lead to major surgical decisions.

Modifier GC is specific to teaching hospitals where a resident performs the service under a teaching physician's supervision. For E/M codes, Modifier 59 is rarely appropriate and shouldn't be applied to 99202 in most cases. Modifier AT is for chiropractic manipulative treatment codes, not E/M visits.

G2211 Add-On Code with 99202: What Changed in 2026

One of the most significant Medicare medical billing developments affecting 99202 CPT code reimbursement in recent years is the activation of HCPCS add-on code G2211. This code became separately payable on January 1, 2024, and it provides additional reimbursement for office and outpatient visits that reflect the complexity of an ongoing clinician-patient relationship.

What Is G2211?

G2211 is a Medicare add-on code that recognizes visits where the provider serves as the focal point for ongoing care coordination or manages a serious or complex condition over time. It attaches to base E/M codes 99202 through 99215. Beginning January 1, 2026, it also applies to home visit codes 99341 through 99350.

The code isn't specialty-restricted. Any qualifying provider can report it when the visit context supports a longitudinal care relationship.

When Can G2211 Be Billed with 99202?

G2211 may be reported alongside 99202 when the new patient encounter establishes a care relationship intended for ongoing management. Think of a new patient coming in for an initial evaluation of a chronic condition that will require continued monitoring and treatment.

The visit must reflect the provider's role as the primary point of care coordination. When it does, the additional reimbursement adds up: roughly $16 to $17 per eligible visit under the 2026 Medicare fee schedule.

For practices seeing a high volume of new patients with chronic conditions, those dollars compound quickly.

G2211 and Modifier 25 Interaction (2025-2026 Rule Change)

This is the part most billing teams miss, and it's where real money gets left on the table.

During 2024, CMS implemented edits that blocked payment of the add-on whenever the associated E/M code carried Modifier 25. If you billed 99202-25 with the add-on code, it got denied. No exceptions.

That changed on January 1, 2025. CMS created a specific exception: the add-on is allowed alongside an E/M code billed with Modifier 25 when the same-day service is one of these:

• Annual Wellness Visit (AWV)

• Vaccine administration

• Any Medicare Part B preventive service

This exception carries into 2026.

Here's the practical takeaway: if a new patient comes in for both a problem-oriented evaluation (99202-25) and a preventive service or vaccine on the same date, your practice can report 99202-25 plus G2211 plus the preventive service code. That combination maximizes legitimate reimbursement for complex same-day encounters without triggering payment edits.

Can 99202 Be Used for Telehealth? Billing Requirements for 2026

Yes. CMS and most commercial payers allow CPT 99202 for qualifying telehealth visits in 2026. The same time and MDM requirements apply as for in-person encounters. Medicare doesn't recognize the telemedicine-specific CPT codes (98000 through 98015) but covers telehealth E/M services when billed with standard office visit codes plus the appropriate modifier.

Whether the visit happens over video or audio only, the requirements for 99202 CPT code telehealth billing are specific:

Getting the place of service code right matters. Use POS 02 when the patient connects from a clinical location like a community health center. Use POS 10 when they're at home. A wrong POS code won't always cause a denial, but it can trigger payer review and delay reimbursement.

For audio-only encounters where the patient can't access video, Modifier 93 applies. Not every payer reimburses these visits at the same rate as video encounters, so verify individual policies before billing. Some payers don't cover audio-only E/M visits at all.

Commercial payer telehealth policies vary significantly from Medicare's rules. Some require specific documentation checklists, originating site requirements, or geographic restrictions. Confirm each payer's requirements before submitting claims to avoid preventable rejections.

ICD-10 Codes Commonly Paired with CPT Code 99202

Every CPT code 99202 must be paired with an appropriate ICD-10-CM diagnosis code to demonstrate medical necessity. Claims submitted without a valid diagnosis code, or with a code that doesn't support the level of service billed, are subject to denial. Below are ICD-10 codes frequently paired with 99202 based on the straightforward, low-acuity clinical scenarios this code represents.

Providers should select the most specific ICD-10 code supported by their documentation. Unspecified codes ending in .9 should only be used when further specificity isn't clinically available at the time of the encounter. Using overly generic codes when specificity is documented may trigger payer review.

Common 99202 Billing Mistakes and How to Prevent Denials

Despite being one of the most frequently billed E/M codes, 99202 CPT code continues to generate a disproportionate share of coding errors and claim denials. CMS audit findings indicate that nearly one in four 99202 claims contains a documentation or coding issue. Understanding the most common mistakes and implementing targeted prevention strategies is essential for protecting practice revenue.

Top Denial Reasons for 99202 Claims

1. Billing 99202 for an established patient.
The error: failing to verify the three-year rule and applying a new patient code to someone previously seen within the same specialty and group. The fix: implement a verification step in the intake workflow that checks EHR records and prior claims before code assignment.

2. Insufficient time documentation.
The error: recording vague entries like "spent time with patient" or omitting total time entirely. The fix: record specific minutes and briefly describe activities performed.

3. Under-documenting medical decision making.
The error: failing to document problem complexity, data reviewed, and risk level when billing by MDM. The fix: use structured documentation templates that prompt for each MDM element.

4. Overlapping with preventive services.
The error: billing 99202 alongside a preventive visit without documenting a distinct, separately identifiable clinical problem. The fix: use Modifier 25 on 99202 and ensure the E/M note addresses a separate clinical issue.

5. Counting non-provider time.
The error: including nursing or medical assistant time in the total time calculation. The fix: only count time personally spent by the billing provider.

6. Using 99202 for the wrong setting.
The error: applying 99202 to inpatient, observation, or emergency department encounters. The fix: remember that 99202 is exclusively for office or other outpatient settings.

7. Miscoding 99202 when documentation supports a higher code.
The error: habitually defaulting to 99202 when the encounter actually supports 99203 or 99204. The fix: audit coding patterns quarterly to identify systematic undercoding.

Audit Risk Factors

Denial Prevention Best Practices

1. Conduct quarterly internal chart audits on a random sample of 99202 claims.

2. Train all billing staff on the 2021 E/M guidelines and 2026 payer policy updates.

3. Use EHR templates with built-in MDM prompts and time tracking.

4. Review denial reports monthly to identify recurring patterns.

5. Consider partnering with a specialized medical billing service that includes pre-submission coding review.

Claim denials cost the average practice 5 to 10 percent of annual revenue. MedSole RCM's denial management services and AR follow-up programs are built to identify denial patterns, correct root causes, and recover lost revenue. Combined with our outsourced medical billing services at 2.99 percent of collections, practices gain a complete defense against revenue leakage.

Frequently Asked Questions About CPT Code 99202

What is CPT code 99202 used for?

CPT code 99202 is used to report an office or other outpatient visit for the evaluation and management of a new patient. It applies when the visit involves straightforward medical decision making or when the total provider time on the date of the encounter is 15 to 29 minutes. This code is commonly used across primary care, mental health, chiropractic, dermatology, and specialty medicine for initial evaluations of low-complexity conditions such as minor rashes, seasonal allergies, sore throats, and mild musculoskeletal complaints.

How long should a 99202 visit last?

A visit billed under CPT code 99202 requires a minimum of 15 minutes of total provider time on the date of the encounter. The maximum time before advancing to the next code (99203) is 29 minutes. Total time includes both face-to-face interaction and non-face-to-face activities such as reviewing records, documenting the encounter, counseling the patient, and coordinating care. Only time personally spent by the billing provider counts. Staff time can't be included.

How much does Medicare pay for 99202 in 2026?

The 2026 Medicare national non-facility reimbursement rate for CPT 99202 is approximately $72, based on the CMS Physician Fee Schedule. The facility rate is approximately $46. Actual reimbursement varies by geographic locality, ranging from approximately $63 to $88. For 2026, CMS finalized two conversion factors: $33.57 for qualifying APM participants and $33.40 for non-QP physicians. Commercial payer rates are typically higher, averaging $80 to $110 depending on the insurer and contract terms.

What is the difference between 99202 and 99203?

99202 vs 99203 comes down to MDM and time. CPT 99202 requires straightforward medical decision making and covers visits of 15 to 29 minutes, while 99203 requires low complexity MDM and covers visits of 30 to 44 minutes. The MDM distinction means 99202 typically addresses one self-limited problem with minimal data review and minimal risk. In contrast, 99203 involves two or more minor problems or one stable chronic condition, with limited data review and low risk such as prescription drug management. The 2026 Medicare reimbursement difference is approximately $35 per visit.

What is the difference between 99202 and 99212?

The primary difference between CPT code 99202 vs 99212 is patient status. CPT 99202 is for new patients who haven't been seen by the same provider or same-specialty group within the past three years. CPT 99212 is for established patients who have been seen within that timeframe. Both codes require straightforward medical decision making, but they differ in time range (99202 requires 15 to 29 minutes; 99212 requires 10 to 19 minutes) and reimbursement (99202 reimburses approximately $72 vs $52 for 99212 under 2026 Medicare).

Who can bill CPT code 99202?

CPT code 99202 can be billed by physicians (MD and DO), nurse practitioners (NP), and physician assistants (PA). Some payers also allow clinical psychologists to bill E/M codes within their scope of practice. Only time personally spent by the billing provider counts toward the 15-minute threshold. CPT 99202 is a new patient code and generally can't be billed under incident-to arrangements, which apply only to established patients.

Is CPT code 99202 still valid in 2026?

Yes. CPT code 99202 remains an active, valid code in 2026. It wasn't affected by the 2021 deletion of CPT 99201. CMS continues to recognize 99202 for Medicare reimbursement, and no changes to its descriptor or requirements have been announced for future code cycles. It is currently the lowest-level new patient E/M code for office or outpatient visits.

Does CPT code 99202 need a modifier?

CPT code 99202 doesn't require a modifier when billed as a standalone E/M service. However, Modifier 25 is required when a significant, separately identifiable E/M service is performed on the same day as a minor procedure. For telehealth visits, Modifier 95 (audio and video) or Modifier 93 (audio-only) is required depending on the service delivery method. Always verify modifier requirements with each individual payer.

Can 99202 be used for telehealth?

Yes. CMS and most commercial payers allow 99202 CPT code telehealth visits in 2026. The same time and MDM requirements apply as for in-person encounters. Use Modifier 95 for synchronous audio and video visits and Modifier 93 for audio-only encounters. Ensure the correct place of service code (POS 02 or POS 10) is used. Document patient consent and the technology platform used for the encounter.

What is the RVU value for CPT code 99202?

The total RVU for CPT 99202 in a non-facility setting is approximately 1.83, composed of 0.93 work RVUs, 0.85 practice expense RVUs, and 0.05 malpractice RVUs. The facility total RVU is lower due to reduced practice expense allocation. Medicare payment is calculated by multiplying the total RVU by the CMS conversion factor ($33.40 for non-QP physicians in 2026), adjusted by the Geographic Practice Cost Index (GPCI) for the provider's locality.

What is an example of a 99202 visit?

A common example is a new patient presenting with a three-day history of mild sore throat. The provider takes a focused history (no fever, no difficulty swallowing), performs a limited examination (mild pharyngeal erythema, no tonsillar exudate), diagnoses acute pharyngitis (ICD-10 J02.9), and recommends supportive care with OTC ibuprofen. The medical decision making is straightforward: one self-limited problem, no data review, minimal risk. Total provider time is 18 minutes. This encounter meets the criteria for 99202 by both MDM and time.

What is the best medical billing company for small practices?

The best medical billing company for small practices combines affordable pricing with comprehensive revenue cycle management services. MedSole RCM offers outsourced medical billing at 2.99 percent of collections with no hidden fees, making it one of the most affordable billing services in the industry. MedSole also provides provider enrollment and credentialing at $99 per payer, denial management, AR follow-up, and dedicated coding support. For practices seeking to improve clean claim rates, reduce denials, and accelerate reimbursement without the overhead of in-house billing staff, a specialized RCM partner like MedSole delivers measurable results.

Conclusion: Getting 99202 Right Protects Your Revenue

Billing CPT code 99202 accurately isn't complicated, but it does require attention to detail. The code covers new patient office visits with straightforward medical decision making or 15 to 29 minutes of total provider time. Miss the three-year rule, skip the MDM documentation, or count staff time by mistake, and you're looking at denials, recoupments, or audit flags.

The 2026 updates add a few more moving parts. The dual conversion factor, the G2211 add-on opportunity, and the ongoing Modifier 25 scrutiny all affect how practices bill and get paid. Staying current on these changes isn't optional if you want to protect your reimbursement.

Here's what matters most: verify patient status before every visit, document either time or MDM clearly, and match the code to the work actually performed. These basics prevent the vast majority of 99202 problems. When you build them into your workflow, denials drop and collections improve.

For practices that want to focus on patient care instead of claim corrections, working with a billing partner makes sense. MedSole RCM handles the entire revenue cycle, from eligibility verification through final payment posting. Our team catches documentation gaps before claims go out, follows up on underpayments, and resolves denials that would otherwise sit in a queue.

We offer outsourced medical billing services at 2.99 percent of collections with no setup fees and no long-term contracts. Provider credentialing runs $99 per payer. Our denial management and AR follow-up programs are built to recover revenue that most practices write off.

If 99202 denials are eating into your collections, or if your billing team is stretched too thin to keep up with payer policy changes, we should talk. Reach out to MedSole RCM and let's see what's fixable.