New Patient CPT Code Guide: Everything You Need to Know

You must hear the “CPT Coding” terminology in a routine healthcare practice. Do you know the importance of these codes? American Medical Association (AMA) provides a set of numbers or figures to healthcare organizations to use in routine billing and patient records. These codes are called Current Procedural Terminology (CPT) codes. New patient codes are different from normal CPT codes, but you should understand both to streamline routine billing tasks.

In this blog post, we will provide a detailed overview of a new patient CPT code. You will know about when and how these codes are used. We will elaborate on how these codes affect billing practices. Further, we will provide real scenarios and future trends of these CPT codes.

What are New Patient CPT Codes?

CPT codes are classified into different categories. One of these categories is the CPT code for new patient office visits. It is an innovative category that Medicare and AMA introduce to the hospitals. It is specifically for those patients who register themselves in a hospital first time.

Hospital billers assign them a unique and new code that is called the new patient CPT code.

Role of CPT Codes in Medical Billing?

Whether it is a new CPT code or a regular CPT code, both play important roles in medical billing. Medical billing has become efficient and streamlined with the help of this coding system. CPT codes:

• Categorize patients to manage a large number of patients in groups
• Made billing and claim submission easy and simple
• Help in differentiating old or new patient
• Make the diagnosis easy
• Streamline reimbursement process
• Ensure accurate payments for medical services

Definition of New Patient according to CMS and AMA:

To understand codes for new patient office visits, you should know the definition of new patient. According to CMS and AMA, a new patient is someone who has not received professional medical services from a hospital in the last three years.

The classification of new patients is necessary because new patient visits need more comprehensive evaluation and documentation.

Common CPT Codes for New Patient Office Visits:

A new patient CPT code is specifically used in medical billing. CPT codes for new patient office visits fall under the 99202–99205 range. These codes are assigned to the condition and complexity of the disease of the patients.

These codes help in providing accurate bills to patients and insurance companies. These codes are also assigned according to the regulations of CMS. Thus, they help maintain compliance.

Some common CPT Code for office visits for new patients:

99202:

• Level of Service: Straightforward
• MDM Complexity: Minimal
• Typical Time Spent: 15–29 minutes

99203:

• Level of Service: Low
• MDM Complexity: Low
• Typical Time Spent: 30–44 minutes

99204:

• Level of Service: Moderate
• MDM Complexity: Moderate
• Typical Time Spent: 45–59 minutes

99205:

• Level of Service: High
• MDM Complexity: High
• Typical Time Spent: 60–74 minutes

Factors Influencing New Patient CPT Codes Selection:

Selecting the right new patient CPT code is necessary for accurate billing. That is why, you should consider some factors before assigning a code to the patient. Three factors are involved in assigning a CPT code to the new patients.

These factors are:

Medical Decision-Making (MDM):

MDM depends on the number of diagnoses, risks, and the amount of data reviewed during the visit. According to the medical complexity of the patient, this section is filled as low, moderate, and high.

Patient History:

The history of the patient also determines the code for the patient. The history includes the chief complaint, history of present illness, and past medical, family, and social history. The more detailed is history, the more high-level the CPT code will be for the patient.

Physical Examination:

Physical examination also depends on the selection of the right code. High-level codes need a more comprehensive examination. On the other hand, low-level codes need less comprehensive examination. Thus, the extent of the physical exam varies with the complexity of the visit.

Billing Requirements for CPT Code for office visit new patient

Are you admitting a new patient in your hospital? Want to know the billing requirements of the patient for this procedure? It is a simple task because a patient does not need to submit detailed documents except necessary documents.

Billing requirements for CPT code for office visits to new patients are as follows:

Accurate Documentation:

You will submit accurate documents for the patients. For this, you should make sure that the information given is authentic. Check that history, exam, and MDM are all correct and according to the patient's condition. Mention all the information about the patient correctly. 

Medical Necessity:

You should verify that the condition of the patient matches with the level of care a patient needs. For example, a patient is moderately ill according to his history and physical examination. Thus, he will need a code that falls under the moderate new patient CPT code category.

Compliance with CMS and AMA Guidelines:

You should update your CPT code chart with new CMS and AMA guidelines. Then, you should use these codes in your practice regularly. When you use updated guidelines in your hospital, it will help you remain compliant.

Use of Time-Based Coding:

When your coding system is based on time, you should add the time spent on the visit. For example, the 99202 code shows that 15-30 minutes are spent on a visit.

New Patient vs. Established Patient CPT Codes

You should know the clear difference between the CPT code for new patient office visits and established patients.

• New patient codes (99202–99205) require a more detailed history, exam, and MDM. They maximize reimbursement rates for the hospitals.

• Established patient codes (99211–99215) apply to those who have been seen within the past three years. They are used for short and less complex visits.

Scenarios on New Patient Visit CPT Code:

Do you want to know about the advantages of new patient CPT codes? We can illustrate them with the help of real-world scenarios in different hospitals.

Scenario 1: Primary Care Clinic Visit

A new patient presents with mild hypertension and no prior medical records. The physician spends 35 minutes reviewing the history, conducting an exam, and making treatment recommendations. CPT Code will be: 99203 (low complexity, 30–44 minutes).

Scenario 2: Specialist Consultation

A patient with uncontrolled diabetes and heart disease visits an endocrinologist for the first time. The doctor reviews extensive medical records, performs a comprehensive exam, and adjusts the treatment plan. CPT Code will be: 99205 (high complexity, 60–74 minutes).

Trends in New Patient CPT Codes:

CMS and ADA are incorporating technology in the CPT coding system. Some future trends are:

• Some healthcare organizations are using AI-based systems to manage new patient CPT codes.
• They are focusing on time-based coding to reduce time wastage in code selection.
• CMS is encouraging to use of telehealth systems in new patient CPT coding systems.

Conclusion:

In conclusion, understanding a new patient's CPT code is important for accurate medical billing and reimbursement. You can optimize revenue while maintaining compliance with the help of accurate new patient visit CPT codes. The real-world scenarios can help you understand the working mechanism of this coding system. Staying informed about coding updates and industry trends will further enhance billing efficiency and patient care.

To streamline medical billing and ensure compliance with AMA and CMS guidelines, healthcare providers can leverage expert medical billing services from SysmD for accurate CPT coding and efficient reimbursement processing.