New Patient Office Visit Documentation Guidelines

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Lecture
99201

99202

99203

99204

99205

c/c

Required

Required

Required

Required

Required

HPI

1 element

2 elements

4 elements

4 elements

4 elements

ROS

N/A

N/A

2 elements

10 elements

10 elements

PFSH

N/A

N/A

1 element

3 elements

3 elements

1 system

2 systems

5 systems

8 systems

8 systems

Low

Moderate

High

CPT

HISTORY

EXAMINATION

MEDICAL DECISION MAKING = Assessment and Plan

Straightforward

Straightforward

TIME
10 min

20 min

30 min

45 min

60 min

Source: Dr. Peter Jensen, MD, CPC www.emuniversity.com

New Patient Office Visit CPT 99202

6%

$71.00

Internists use this code for 6% of new office patients. Usually the presenting problems are of low to moderate severity. The
reimbursement for this code is approximately $71. 10 minutes spent face-to-face with the patient if coding based on time.
The documentation for this encounter requires THREE out of THREE of the following:
1) Expanded Problem Focused History
2) Expanded Problem Focused Exam
3) Straightforward Medical Decision-Making

68 year old female with allergic rhinitis

CC : Stuffy nose
HPI: Patient states she began having increased nasal congestion about three weeks ago. She states the problem is sometimes quite severe
and is worse when she goes outside. She is concerned she may be developing seasonal allergies. She says the congestion is often
associated with watery eyes and can last for several hours at a time.
Medications: HCTZ 12.5 mg po qd .
PMH : is positive for hypertension
ROS: Ears, Nose, Mouth and Throat - Negative for epistaxis, sore throat or decreased hearing. Pulmonary - Negative for cough, SOB
Physical Exam
General: NAD, conversant; looks about her stated age
Vitals: 130/72, 88, 98.6
Head: NC/AT, no sinus tenderness or submandibular lymphadenopathy
Neck: Supple without lymphadenopathy; trachea midline
Eyes: anicteric sclerae with moist, pale conjunctiva and no lid lag
Nose: normal non-injected nasal mucosa, with normal septum and turbinates
Oropharynx: No mucosal ulcerations, normal hard and soft palate. No pharyngeal erythema
Ears: Patent external auditory canals with pearly TMs and normal hearing acuity
Lungs: CTA
CV: RRR with no MRGs
Extremities: no edema
Assessment
1. Possible allergic rhinitis in a patient with optimally controlled HTN
Plan
1. OTC acetaminophen and diphenhydramine
2. Saline nasal flushes
3. Patient was instructed to avoid decongestants with phenylpropanolamine due to the risk of exacerbating her hypertension

New Patient Office Visit Documentation Guidelines

New Patient Office Visit CPT 99203

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29%

$103.00

99203 is the most frequently used code for new office patients. Internists use this code for 29% of these encounters. The reimbursement for
this visit is about $103. Usually the presenting problems are of mild to moderate severity. 30 minutes spent face-to-face with the patient if
coding based on time.
The documentation for this encounter requires THREE out of THREE of the following:
1) Detailed History
2) Detailed Exam
3) Low Complexity Medical Decision-Making

68 year old female with allergic rhinitis

CC : Stuffy nose
HPI: Patient states she began having increased nasal congestion about three weeks ago. She states the problem is sometimes quite
severe and is worse when she goes outside. She is concerned she may be developing seasonal allergies. She says the congestion is
often associated with watery eyes and can last for several hours at a time.
Medications: HCTZ 12.5 mg po qd .
PMH : is positive for hypertension
ROS: Ears, Nose, Mouth and Throat - Negative for epistaxis, sore throat or decreased hearing. Pulmonary - Negative for cough, SOB
Physical Exam
General: NAD, conversant; looks about her stated age
Vitals: 130/72, 88, 98.6
Head: NC/AT, no sinus tenderness or submandibular lymphadenopathy
Neck: Supple without lymphadenopathy; trachea midline
Eyes: anicteric sclerae with moist, pale conjunctiva and no lid lag
Nose: normal non-injected nasal mucosa, with normal septum and turbinates
Oropharynx: No mucosal ulcerations, normal hard and soft palate. No pharyngeal erythema
Ears: Patent external auditory canals with pearly TMs and normal hearing acuity
Lungs: CTA
CV: RRR with no MRGs
Extremities: no edema
Assessment
2. Possible allergic rhinitis in a patient with optimally controlled HTN
Plan
4. OTC acetaminophen and diphenhydramine
5. Saline nasal flushes
Patient was instructed to avoid decongestants with phenylpropanolamine due to the risk of exacerbating her hypertension

New Patient Office Visit CPT 99204

43%

$158.00

Internists select the 99204 code for 43% of their encounters. The reimbursement for this level of care is approximately $158. Usually the
presenting problems are of moderate to high severity. 45 minutes spent face-to-face with the patient if coding based on time.
The documentation for this encounter requires THREE out of THREE of the following:
1) Comprehensive History
2) Comprehensive Exam
3) Moderate Complexity Medical Decision-Making

A patient with stable hypertension and diabetes

CC : I need a primary physician.
HPI : The patient is a pleasant 71 year old gentleman who presents to establish care with the physician after relocating to this area. He
has a history of hypertension and diabetes, both of which have been controlled with routine medications. He also reports a history of
coronary artery disease, which has been quiescent over the past two to three years following PTCA and stent deployment. He has no
spontaneous somatic complaints.
Medications
Atenolol 25 mg PO QD
Glyburide 5 mg PO BID
Lisinopril 10 mg PO BID
Atorvastatin 20 mg PO QD
PMH : per HPI, plus osteoarthritis and dyslipidemia

New Patient Office Visit Documentation Guidelines

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ROS :Complete ROS was performed and documented and was positive for intermittent lower extremity edema and easy bruising. For
more details, please refer o the ROS questionnaire with todays date located in the chart.
FH : Mother died in her 80s of old age; father at age 72 of pneumonia. The patient has three grown children in good health.
SH : The patient has been married for 45 years. He denies tobacco or alcohol abuse and continues to drive himself around.
Physical Exam
Vitals: 130/80, 88, 98.6
General appearance: NAD, conversant
Eyes: anicteric sclerae, moist conjunctiva; no lid-lag; PERRLA
HEENT: AT/NC; oropharynx clear with MMM and no mucosal ulcerations;auditory canals patent with pearly TMs
normal hard and soft palate Neck: Trachea midline; FROM, supple, no thyromegaly or lymphadenopathy
Lungs: CTA, with normal respiratory effort and no intercostal retractions
CV: RRR, no MRGs
Abdomen: Soft, non-tender; no masses or HSM
Extremities: No peripheral edema or extremity lymphadenopathy
Skin: Normal temperature, turgor and texture; no rash, ulcers or nodules
Psych: Appropriate affect, alert and oriented to person, place and time
Labs: HGBA1c 6.8; BUN 25, creatinine 0.8; LDL 88, HGB 12
Assessment
1. Well controlled essential hypertension
2. Optimally controlled NIRDM
3. Stable dyslipidemia
4. Stable CAD
Plan
1. Continue current medications unchanged
2. Return visit in three months
3. Will check repeat HGBA1c, CBC, and renal profile
4. Will also check LFTs since patient is on statin medication
5. Will also check spot microalbumin/creatinine

CPT Coding Guidelines:

5 Types of Presenting Problems

Minimal: A problem that might not require the presence of the physician, but service is provided under the physician's
supervision.
Self-limited or minor: 99201, 99202 A problem that runs a definite and prescribed course, is transient in nature and is
not likely to permanently alter health status or that has a good prognosis with management and compliance.
Low severity: 99203
A problem where there is little to no risk of mortality without treatment; full recovery without functional impairment is
expected.
Moderate severity: 99204
A problem where there is moderate risk of mortality without treatment, an uncertain prognosis or increased probability of
prolonged functional impairment.
High severity: 99205 A problem where there is a moderate to high risk of mortality without treatment or high probability of
severe, prolonged functional impairment