New Patient Office Visit – 15 to 29 Minutes

CPT Code: 99202

Description: This code is used for a new patient office or outpatient visit that typically lasts between 15 and 29 minutes of face-to-face time. It involves a straightforward medical decision making (MDM) process.

Key Components:

• History: Problem-focused or expanded problem-focused
• Examination: Problem-focused or expanded problem-focused
• Medical Decision Making: Straightforward

Alternatively, the level of service can be determined based on the total time spent during the encounter (including counseling and coordination of care).

Documentation Tips:

• Clearly record the time spent and the key components of the encounter.
• Document sufficient details to support the straightforward MDM.
• Ensure compliance with current CPT and payer documentation requirements.