CPT Code 99202 Billing and Coding Reference Guide 2026

Half of new patient claims contain a coding error. The risk on 99202 starts before the note is closed, and most practices have no visibility into it until a denial lands.

Roughly half of all new patient claims submitted contain a coding error of some kind, a pattern confirmed by a June 2026 review, which found only approximately 55% of E/M visits are accurately coded industry-wide. That figure applies to routine visits, standard intake appointments, and the kind of straightforward new patient encounters that billing teams process dozens of times each week. The common assumption among practice administrators and billing decision-makers is that mastering CPT 99202 criteria, MDM thresholds, time rules, new-patient definitions, is sufficient to protect revenue, because once coders know the rules the claims will be accurate. Understanding where that error rate originates starts with the code at the bottom of the new patient hierarchy: CPT code 99202.

55%

of E/M visits accurately coded industry-wide

See our AI medical scribe for how this works in practice. Most practice administrators treat that same figure as a lookup task, something you confirm after the note is closed and the visit is done.

Coding level selection is a revenue decision, and the documentation that supports it is either built during the encounter or it is not built at all. Practices that recognize this early, including those using ambient AI documentation to capture clinical detail in real time, are closing a gap that retrospective coding simply cannot reach.

CPT code 99202 is the entry-level code for a new patient office or other outpatient evaluation and management visit, sitting at the base of the that same figure through 99205 hierarchy established by the AMA and administered through CMS policy. Each code level in that range is tied to specific medical decision-making complexity or total time thresholds that directly determine reimbursement amounts, a structure codified by the AMA's 2021 E/M revisions and carried forward into the 2026 fee schedule. One structural fact matters here: the AMA permanently deleted CPT code 99201, making 99202 the floor and shifting the documentation threshold upward for the lowest-tier claim.

The that same figure through 99205 range is not a flat list. Each step up represents a meaningful reimbursement increase; each step down represents revenue the practice earned but did not collect. Undercoding leaves reimbursement on the table, while overcoding without supporting documentation creates audit liability the practice cannot defend. A June 2026 review found that only approximately 55% of E/M visits are accurately coded industry-wide, and 99202 encounters absorb a disproportionate share of that risk because they sit at the boundary where both error types are common and difficult to detect before a denial or audit surfaces them.

The gap is visibility. Billing staff working from finalized notes are reconstructing clinical context after the encounter is closed, and the ceiling on what a coder can support is set entirely by what the provider documented in the moment. Knowing what CPT that same figure is, however, is only the first gate. The real billing risk lives in the specific criteria that make an encounter legally billable at this level, and that is exactly where the next section picks up.

Key takeaways

• Only ~55% of E/M visits are accurately coded industry-wide, meaning nearly half of every CPT 99202 claim your practice submits carries either a revenue loss or an audit risk baked in before the payer ever sees it.
• The new-patient qualification question must be answered cleanly before any clinical documentation begins; a wrong call there creates compliance exposure that no downstream coding precision can fix.
• CPT 99202 requires all three MDM components, problem, data, and risk, documented independently and simultaneously; a note that proves two out of three doesn't hold up on audit.
• The time-based pathway isn't a simpler alternative to MDM; it carries its own documentation traps, and unlogged time segments cannot be reconstructed after the note is finalized without creating compliance risk.
• The per-visit dollar gap between 99202 and 99203 is not a rounding error, it compounds quietly across every new patient encounter billed below its defensible level.
• The 99202 vs. 99203 decision is a documentation capture problem, not a coder knowledge problem, which means coder training alone cannot fix it.
• iScribe Health's Automated E&M Coding applies coding intelligence directly from the clinical narrative before the note is finalized, so the code that reaches the payer reflects everything the encounter actually supported, not just what survived the documentation process.

Key Requirements and Criteria for Billing 99202 in 2026

A valid CPT claim lives or dies on one structural decision made before the claim ever reaches a payer: which pathway governs code selection for this encounter, and does the documentation fully support that choice?

The Two Compliant Pathways to 99202 and Why Picking the Wrong One Costs You Money

Two mutually exclusive pathways govern code-level selection for office and outpatient E/M visits: Medical Decision Making (MDM) and total time on the date of the encounter. Selecting the wrong pathway, or attempting to blend elements of both, is one of the most common sources of claim denial and audit exposure at this code level.

What Medically Appropriate History and Exam Actually Requires in Documentation

As the AAPC Knowledge Center confirms, history and physical examination must still be performed and documented as medically appropriate, but their extent no longer determines the level of the E/M code. What "medically appropriate" means in practice is that the note must reflect clinical judgment about what was warranted for that patient on that date, not a templated checklist completed out of habit.

This is where provider misconceptions create real billing exposure. A note that documents an exhaustive review of systems but omits explicit MDM components will not support the code, regardless of how thorough the visit appeared clinically.

MDM vs. Total Time Scored Against Your Practice's Documentation Reality

Choosing between the two pathways should be driven by which one the existing documentation can actually defend. If the encounter involved extended counseling or care coordination that pushed total time to 22 or 25 minutes, the time pathway may be more defensible, provided the note records total time explicitly.

The critical failure point is retrospective reconstruction. A provider who spent 22 minutes on a new patient visit but documented only the chief complaint and a brief exam has a time pathway that is valid in theory and unprovable in practice. This is where iScribe Health's automated scribing layer identifies which pathway the documented encounter actually supports and flags the gap in real time, before the note is finalized and before the claim is submitted.

CPT 99202 Pathway Selection - Quick-Reference Decision Checklist

Step 1, Confirm New-Patient Status

• No same-specialty provider within this group practice has seen the patient in the past 3 years

Step 2, Choose One Pathway (select and document only one)

• MDM → Minimum Requirement: Straightforward: minor/self-limited problem + minimal data + minimal risk → Documentation Must Include: All 3 MDM components explicitly stated in the note.
• Total Time → Minimum Requirement: 15–29 minutes on the date of the encounter → Documentation Must Include: Exact total minutes + description of all qualifying activities.

Step 3, Confirm MDM Components (if MDM pathway selected)

• Problem type documented (minor or self-limited)
• Data reviewed documented ("no outside records reviewed" is acceptable)
• Risk level documented ("minimal risk; self-limited condition" is acceptable)

Step 4, Confirm Time Components (if time pathway selected)

• Total minutes on date of service explicitly stated
• Non-face-to-face activities described (pre-visit review, post-visit charting, etc.)

Step 5, Code Selection Checkpoint

• If any MDM component exceeds minimal → consider 99203
• If total time ≥ 30 minutes → consider 99203
• If total time < 15 minutes → the time pathway cannot support that same figure; shift to the MDM pathway if documentation supports straightforward complexity, or bill the appropriate lower-level code

What Defines a New Patient for CPT Code 99202

Before any provider documents a single finding, and before any coder touches a complexity level, one structural question must be answered cleanly: does this patient legally qualify as new under the AMA's definition?

"As someone learning medical billing and coding, I struggle to find reliable resources that clearly define what constitutes a new patient in the context of CPT codes like 99202/99203; textbooks contain inconsistent or incorrect answers."

— what we hear from medical billing and coding students

The AMA's Three-Year Same-Specialty Rule

A new patient for CPT 99202 is one who has not received any professional services from the physician, or another physician of the same specialty or subspecialty within the same group practice, within the past three years. That definition comes directly from the AMA CPT Guidelines, and it has nothing to do with location. If a same-specialty provider in the same group saw them 18 months ago, they are an established patient.

When the New-Patient Gate Closes

If a patient has been seen by any provider of the same specialty within the same group practice within the past three years, established patient codes (CPT 99211-99215) must be used instead, per CPT Guidelines. Misclassifying that patient as new is a recognized audit red flag.

The Same-Group Different-Specialty Edge Case

A patient seen by a provider of a different specialty within the same group may still qualify as new, because the three-year look-back applies only to same-specialty providers. A patient who saw the group's cardiologist 18 months ago and now presents to the group's internist can legitimately qualify as new for that internist, provided no same-specialty provider has seen them in the prior three years.

Straightforward Medical Decision Making Requirements for 99202

That is the complete definition of straightforward medical decision making for CPT that same figure, and the clinical note must prove all three independently before the code holds up on audit.

What Straightforward MDM Actually Requires - The Three-Part Test Explained

Straightforward MDM for CPT that same figure requires a minor or self-limited presenting problem, minimal or no data reviewed, and minimal risk of complications or morbidity. Classic qualifying examples include a cold, a minor insect bite, or a simple rash.

Why Explicit MDM Notation Is Non-Negotiable Even for Minor Visits

iScribe Health addresses this at the only point in the workflow where documentation can actually be corrected: at the point of note completion, after the AI drafts the encounter summary. Using ambient listening and conversational AI, iScribe Health's E&M Coding Intelligence layer identifies which of the three MDM components are missing from the drafted note and surfaces them before the provider finalizes the record.

Straightforward MDM is the most defensible pathway for that same figure, but only when all three components are explicitly in the note.

Related Reading

• Cpt Code 99233
• Cpt Code 99203
• Cpt Code 99232
• Cpt Code 99244
• Cpt Code 99221
• Cpt Code 99205
• Cpt Code 99223
• Cpt Code 99222

Time Threshold Requirements for CPT Code 99202

The 15-29 Minute Rule What Counts Toward CPT 99202's Time Threshold

Qualifying non-face-to-face activities include reviewing records before the visit, documenting the chart after the encounter, and ordering and reviewing test results.

That totals 26 minutes, which comfortably qualifies for that same figure on time, but only if the note explicitly states "26 minutes total on [date of service]."

Why Undocumented Time Is a Bigger Liability Than No Time Pathway at All

CMS is explicit that when billing on time, the provider must document total time spent on the date of the encounter, not merely face-to-face contact time.

iScribe Health's automated scribing is built to capture the full arc of provider work, including non-face-to-face time, and surface a compliant time attestation before the note closes, so qualifying minutes are recorded at the moment they occur rather than reconstructed after the fact.

CPT 99202 Reimbursement Rates and Medicare Payment for 2026

It is a per-visit dollar figure that compounds quietly across every new patient encounter your practice bills below its defensible level.

2026 Medicare Reimbursement Rates for CPT 99202 in Non-Facility and Facility Settings

The CMS Physician Fee Schedule Look-Up Tool sets the national non-facility rate for CPT 99202 at approximately $93.05 per encounter, while the facility rate drops to approximately $67.11.

• CPT 99202 → Non-facility (office): ~$93.05 → Facility: ~$67.11.
• CPT 99203 → Non-facility (office): ~$135.71 → Facility: ~$97.73.

That documentation pressure quietly pulls coding downward, and the revenue loss never appears on a single alarming line item. iScribe Health's Ambient AI Documentation and E&M Coding Intelligence are built to intervene at precisely this point: the AI listens during the encounter, drafts the note summary through Ambient Listening and Conversational AI, and applies automated E&M coding logic at the moment of note completion, before the documentation gap has any chance to form.

The Revenue Gap Hidden When Undercoding 99202 Instead of 99203

$42.66 per visit. That is the non-facility spread between 99202 and 99203 under the 2026 fee schedule, per the CMS Physician Fee Schedule Look-Up Tool. In a facility setting, the gap narrows to $30.62 but remains material at any meaningful volume.

A practice seeing 1,000 new Medicare patients annually that systematically bills 99202 when the encounter legitimately supports 99203 forfeits roughly $42,000 to $43,000 per year in non-facility reimbursement alone (CMS Physician Fee Schedule Look-Up Tool). That figure does not include Medicaid shortfalls or commercial payer multipliers.

Most coding decisions happen after the note is finalized, which is precisely when documentation gaps are already locked in. iScribe Health's clinical documentation platform is designed to address this upstream, applying E&M Coding Intelligence during documentation rather than after, through EHR Integration that works within the workflows a practice is already running.

CPT 99202 vs 99203 - How to Choose the Right New Patient Code

The Stable Hypertension Trap When 99203 Is Correct but 99202 Gets Billed

Consider a new patient presenting with two chronic conditions requiring active management. The provider spends 20 minutes, orders a basic metabolic panel, and adjusts no medications.

It simply never made it into the record. iScribe Health's Ambient AI Documentation captures physician dialogue and patient context during the visit to generate clinical notes in under 30 seconds, so the chronic condition management language that supports low-complexity MDM is present in the note at the moment the coder needs it, without adding to the physician's post-visit documentation burden.

Because iScribe Health integrates directly with supported EHRs, the AI-drafted encounter summary materializes at the point of note completion, within the workflow the physician is already using, requiring no separate system or manual transfer.

Time as a Tiebreaker When MDM Is Underdocumented

When MDM documentation falls short, total encounter time offers an alternative pathway to the correct code level.

Ambient listening captures the full encounter, including pre-visit preparation discussion and post-visit coordination, giving the note the specificity required to defend a time-based code without asking the physician to reconstruct it from memory at 8 p.m.

iScribe Health's E&M Coding Intelligence layer then works at the point of note completion: after the AI drafts the encounter summary, it applies automated E&M coding logic to surface the defensible code level the documentation actually supports, flagging cases where the note has captured enough to justify 99203 but the default would have been 99202.

Addressing the full pattern of undercoding requires the same documentation discipline applied consistently across every visit type.

Common Billing Exclusions and Audit Pitfalls for CPT 99202

Isolated documentation gaps at the 99202/99203 boundary are costly, but they rarely account for the full scope of revenue loss a practice absorbs across its new patient claim volume. Industry denial rates run between 5% and 10% of all claims submitted, representing billions in delayed or lost revenue annually, and mastering CPT code-selection criteria, MDM thresholds, time rules, and new-patient definitions is not enough to contain that exposure. The real risk is concentrated at a handful of recurring failure points that sit outside the code-selection decision itself, and most of them are invisible until after the note is locked and the claim is already in flight.

1. Miscategorizing Established Patients as New - The Most Common CPT 99202 Billing Exclusion

Common billing exclusions for that same figure start here: billing a new patient code for someone who received professional services from the same specialty within the same group practice in the past three years. Payers audit this pattern systematically. When a practice bills disproportionate volumes of new patient codes relative to its patient panel age and specialty mix, that ratio alone can flag the entire account for review.

The financial consequence is not just a single denied claim; it is a retroactive audit across every similarly coded encounter in the look-back window. Surfacing these audit candidates upstream, before claims submit, is the only intervention that prevents the retroactive sweep entirely. iScribe Health's Real-Time Denial Alerts are designed to do exactly that: flag the problematic encounter at the point of note completion, while correction is still possible, rather than after the claim has entered a payer's review queue.

2. Upcoding to 99203 Without Supporting MDM - The Audit Trigger Pattern That Flags Entire Practices

The 99202 versus that same figure boundary is the highest-frequency code-selection error in new patient E/M billing. When a provider documents a stable acute illness or a single chronic condition as the presenting problem but the claim goes out as that same figure (straightforward MDM), that is undercoding. The reverse is more dangerous: billing that same figure for an encounter where the clinical note only supports straightforward complexity. According to I-Conic Solutions, coding errors including incorrect CPT code selection are among the top drivers of claim denials, and the failure point is documentation quality at the time of the encounter, not coder knowledge after the fact.

Payers and the OIG flag practices where that same figure billing rates run statistically high compared to peer groups, triggering reviews that sweep in every new patient visit billed over a rolling period. iScribe Health's E/M Coding Intelligence applies coding awareness during documentation, at the moment the AI drafts the encounter summary, so the MDM narrative either supports the code being considered or signals the mismatch before the note is finalized. In high-volume practices where clinicians regularly chart two or more hours outside of patient care time, that real-time feedback loop replaces the discovery-after-submission pattern that currently drives most of these audit triggers.

3. 33% Overcoding Rate Across 941 Encounters - Real-World Audit Data Quantifying CPT 99202 Revenue Risk

One audit tells the story clearly. A real-world review of 941 encounters at the Center for Sports Medicine & Orthopaedics in Chattanooga, documented by Allzone Management Services, found a 33% overcoding rate, directly contradicting the assumption that rule-mastery translates to claim accuracy. Provider-AI coding agreement came in at 54.8%, so a substantial share of encounters carried a code that did not match what the clinical narrative actually supported, and until they ran the trial, no one in the building knew the split. Industry-wide, the same trend holds, and the orthopedic audit reflects a structural condition, not an isolated training failure.

The gap is visibility, and it compounds daily across every encounter a practice bills. iScribe Health's Automated E/M Coding, delivered through Ambient AI Documentation integrated directly into supported EHRs, closes that visibility gap by surfacing coding intelligence at the moment documentation is generated, not during a retrospective audit weeks or months later.

4. E/M Billing and Coding Tips That Prevent CPT 99202 Claim Denials Before Submission

Standard billing and coding tips for E/M accuracy focus on post-submission review: scrubbers, denial queues, appeal workflows. Those controls catch errors after the revenue is already at risk. I-Conic Solutions identifies documentation gaps as a primary structural cause of revenue loss, distinct from and compounding coder knowledge gaps. The only moment when a missing total-time notation or an underdeveloped MDM narrative can be corrected is before the note is finalized. Most practices treat documentation and coding as sequential steps, and that sequencing is the structural flaw.

iScribe Health's E/M Coding Intelligence applies coding awareness during documentation rather than after the note is locked, addressing the structural gap at the moment when MDM elements and time can still be accurately captured, rather than discovered retroactively during an audit. For practices already running a supported EHR, EHR Integration means this intelligence materializes seamlessly inside existing workflows, with no parallel system for clinicians to manage.

Every pitfall in this section shares a structural root cause: the clinical narrative was already finalized before anyone with coding intelligence reviewed it. As I-Conic Solutions makes clear, that documentation-first, coding-second sequence is where revenue exposure originates, not in coder training failures or isolated human error. The next section shows how one intervention, applied at the moment of documentation rather than after, closes that gap permanently.

Related Reading

• Cpt Code 99284
• Cpt Code 99396
• Cpt Code 99395
• Cpt Code 99385
• Cpt Code 99499
• Cpt Code 99386
• Cpt Code 99283
• Cpt Code 99024

How Automated E/M Coding Closes the 99202 Revenue Gap Before the Note Is Finalized

Coder training solves the wrong problem. By the time a skilled biller reviews a finalized note, the clinical encounter is over, the narrative is locked, and any MDM element or unlogged time segment that wasn't captured during the visit cannot be reconstructed without creating compliance risk. As a general principle, coding intelligence applied after the fact to a locked clinical narrative cannot recover revenue lost to incomplete documentation at the point of care. That's the structural ceiling most practice administrators never see.

Why Coders Working From Finalized Notes Face a Hard Revenue Ceiling

The failure point is the note itself. Once the note is signed, the gap is permanent. Amending a finalized note to add MDM complexity or additional time creates its own audit exposure. The documentation gap is created during the encounter, not after it. Retrospective coding review, no matter how thorough, is working against a fixed ceiling it did not set.

How Real-Time Documentation Capture Simultaneously Satisfies Both the MDM and Time Pathways

The three MDM components and total encounter time must all be present in the finalized note to support a defensible claim:

• Problem type
• Data reviewed
• Risk level

A provider dictating a new patient visit in real time, with AI medical scribe technology capturing each component as the encounter unfolds, exits note finalization with both pathways already documented and defensible.

Embedding coding intelligence into the documentation workflow, rather than applying it retrospectively, improves both efficiency and accuracy of clinical coding, according to what most teams report.

How to Achieve Consistent, Defensible 99202 Coding Across Your Billing Team

A billing team working from finalized notes produces inconsistent output because documentation quality varies by provider, by visit pace, and by end-of-day fatigue. When iScribe Health's Automated E/M Coding is embedded in the encounter workflow, coding intelligence prompts for all three MDM components, logs qualifying time including non-face-to-face segments, and flags complexity in real time, so the note exits finalization with the clinical and coding detail needed to support the correct level, reducing the gap between what the provider earned and what the claim can defend.

The documentation gap that drives revenue loss is a timing problem, and it has a timing solution.

Next steps

If your new patient visits are consistently billing below what the clinical encounter actually supported, the path forward starts with moving coding intelligence upstream of the finalized note. The 99202/99203 boundary is not a coder knowledge problem: a coder reviewing a locked narrative can only work with what survived the documentation process, and a stable chronic condition like hypertension that qualifies for low-complexity MDM never elevates the code if the clinical narrative omits the evidence. At $42.66 per encounter in lost non-facility reimbursement, that silence compounds invisibly across every new patient visit on the schedule. Start with our AI medical scribe.

The three-part MDM test means that a single missing component (problem type, data reviewed, or risk level) collapses a defensible 99202 claim into an audit liability, even when the encounter genuinely met the threshold. The unlogged non-face-to-face time problem means that qualifying minutes spent on pre-visit record review and post-visit charting vanish from the reimbursable record the moment the note closes without an explicit time attestation. Together, they point to one intervention: coding awareness embedded in the clinical narrative before the provider signs, not applied retrospectively to a locked note.

Start with an AI medical scribe that captures MDM components and total encounter time in real time, so the documentation that exits note finalization is already the defense layer your claims need before they reach a payer.

Frequently Asked Questions

What's the difference between 99202 and 99203?

99203 Is the next level up in the new patient hierarchy and applies when any single MDM component exceeds the minimal/straightforward threshold, or when total time reaches 30 minutes or more. If a problem sounds minor but carries a higher risk profile, like a rash with uncertain etiology or a cough in a patient with asthma history, the MDM level rises and 99203 becomes the appropriate code, not 99202.

Does a patient who saw a different doctor in the same practice still count as a new patient?

It depends on specialty. If the prior provider was a different specialty, the patient can still qualify as new under CPT rules, because the three-year look-back applies only to same-specialty providers within the same group. A patient who saw the group's cardiologist 18 months ago can legitimately be a new patient for the group's internist, as long as no same-specialty provider has seen them in the prior three years.

Can I skip documenting the history and physical on a 99202 visit since they no longer drive the code level?

No. While history and physical examination no longer determine the E/M code level, they must still be performed and documented as medically appropriate. An auditor reviewing a 99202 claim with no documented history and no exam findings has grounds to question whether the visit occurred as billed, regardless of which coding pathway was selected.

How many minutes does a visit need to last to bill 99202 using the time pathway?

Total time on the date of the encounter must fall between 15 and 29 minutes to support 99202 under the time pathway. The note must explicitly state the total minutes and describe all qualifying activities, including non-face-to-face work like pre-visit review and post-visit charting. If total time is under 15 minutes, the time pathway cannot support 99202.

What exact language in the note satisfies the MDM data and risk components for a straightforward 99202 visit?

The post gives two concrete examples: "no outside records reviewed, clinical decision based on exam alone" satisfies the data component, and "minimal risk; self-limited condition, no prescription required" addresses the risk component. Both phrases are brief but necessary, omitting either means the note cannot be defended at straightforward MDM on audit, even if the encounter genuinely met that threshold.