New patient CPT codes (99202–99205) accounted for $256.1 million in improper Medicare payments, according to CMS. Most of that risk traces back to just two decisions: whether the patient is truly new, and which visit level the documentation actually supports. Both are straightforward — until they're not.

This guide gives you a complete, current reference for new patient CPT coding in 2026: the definitions, the formulas, the modifiers, and the specific scenarios where experienced coders still make expensive mistakes.

$256M
Improper Medicare payments linked to new patient CPT coding
CMS / AAPC, 2024
4
Active new patient office visit codes — 99202 through 99205 (99201 deleted 2021)
AMA CPT, 2026
3 yrs
Lookback window that determines new vs. established patient status
AMA / CMS, 2026

What Are New Patient CPT Codes?

New patient CPT codes are a subset of Evaluation and Management (E/M) codes used to report an office or outpatient visit with a patient who has not previously received a professional service from the provider, or from any other provider of the same specialty and subspecialty in the same group practice, within the past three years.

The new patient family in 2026 consists of four core families:

Office Visit Codes (99202–99205)

Problem-oriented visits with a new patient. Level determined by MDM or total time. Most common family for new patient encounters.

Consult Codes (99242–99245)

When another provider requests your opinion on a specific problem. Note: CMS stopped reimbursing these in 2010 and most payers now require 99202 through 99205 instead.

Preventive Codes (99381–99387)

Wellness exams and physicals for new patients. Selected by patient age, not by MDM or time. Pair with modifier 25 when a problem visit occurs on the same day.

G2211 Longitudinal Add-On

Bills alongside 99202 through 99205 when the provider is the patient's ongoing source of care. Medicare began paying this separately in 2024. Commercial coverage varies, so verify with each payer.

The Three-Year Rule: New vs. Established Patient

The new vs. established determination is the most consequential classification decision in outpatient E/M coding. Bill "new" for an established patient and face recoupment. Bill "established" for a new patient and you are leaving money on the table.

NEW vs. ESTABLISHED PATIENT DECISION TREE Patient arrives for visit Has a same-specialty provider in this group seen them in the past 3 years? NO NEW 99202–99205 Apply YES ESTAB- LISHED 99211–99215 Edge case: Was it diagnostic only (imaging, lab) — no face-to-face visit? Still counts as NEW → 99202–99205 No face-to-face = no established relationship ⚠ TRAP Same group, different specialty = NEW ⚠ TRAP Different group, same specialty = NEW New patient path Established patient path Decision point

The key distinction: "Same specialty" is the operative phrase. A patient seen by a cardiologist in your group is still a new patient to the internist in the same group. A patient transferring from a competing practice is always new, regardless of how recently they were seen elsewhere.

DimensionNew Patient (99202–99205)Established Patient (99211–99215)
EligibilityNo professional service from same-specialty provider in same group within 3 yearsSeen by such a provider within the past 3 years
Level SelectionMDM or total timeMDM or total time
Time Range15–74 min (99202–99205)Up to 54 min (99211–99215)
Typical ReimbursementHigherLower
Payer ScrutinyHigherLower

New Patient Office Visit Codes: 99202–99205

These four codes cover problem-oriented visits with new patients. You select the level based on either medical decision-making complexity or the total time spent on the encounter date. Total time includes pre-visit chart review, documentation, and ordering, not just face-to-face time.

Note: CPT code 99201 was deleted January 1, 2021 when the AMA revised E/M guidelines. The new patient range starts at 99202. Claims still submitted with 99201 will deny. AMA CPT

99202–99205 VISIT LEVEL SELECTOR Choose by MDM complexity OR total time on date of service CPT CODE MDM LEVEL TOTAL TIME TYPICAL CLINICAL SCENARIO 99202 DELETED: 99201 Straightforward 1 self-limited problem 15–29 min ~22 min avg Uncomplicated rash, minor URI, wart removal consult, splinter removal 99203 Low 1+ stable chronic conditions 30–44 min ~37 min avg Controlled hypertension, stable hypothyroidism, allergy follow-through 99204 Moderate New problem, workup needed 45–59 min ~52 min avg Suspected type 2 diabetes, new chest pain requiring labs, undiagnosed chronic condition 99205 High Severe or life-threatening 60–74 min ~67 min avg Threat to life or bodily function, complex multisystem disease, drug toxicity management Document MDM OR Time — not both. Choose one and stick with it.
60%

of 99204 and 99205 claims lack documentation specifying whether MDM or time was the basis for the level selected — a gap that leaves them exposed to downgrade on audit. Always note the basis at the point of documentation.

Consult Codes: 99242–99245

Consult codes apply when a requesting provider asks you to evaluate a patient and render an opinion on a specific problem. The level is set by MDM or by meeting a minimum total time threshold.

Critical payer issue: CMS stopped reimbursing consultation codes in 2010, and most commercial payers followed. In the vast majority of encounters, you will report a standard office visit (99202–99205) instead of a consult code. Always verify payer policy before billing 99242–99245. Code 99241 was deleted in 2023.

CPT CodeMDM LevelMinimum Total TimePayer Acceptance
99241 DELETED 2023——Deleted
99242Straightforward20 minCheck payer policy
99243Low30 minCheck payer policy
99244Moderate40 minCheck payer policy
99245High55 minCheck payer policy

Preventive / Physical Codes: 99381–99387

New patient preventive codes cover wellness exams and annual physicals, not visits for a specific complaint or problem. Selection is based solely on patient age. There is no MDM or time component.

PREVENTIVE CODE SELECTION BY PATIENT AGE New patient (99381–99387) — select by age only <1 1–4 5–11 12–17 18–39 40–64 65+ 99381 Under 1 year Infant wellness 99382 1–4 years Toddler well-child 99383 5–11 years School-age physical 99384 12–17 years Adolescent physical 99385 18–39 years Adult wellness exam 99386 40–64 years Mid-life physical 99387 65+ years Senior wellness ⚠ Adding a problem visit on the same day? Bill 99381–99387 + a problem E/M code (99202–99205) with Modifier 25 on the problem code or you'll lose the second service.

G2211: The Longitudinal Care Add-On

G2211 is an add-on code that recognizes the additional complexity of serving as a patient's ongoing, comprehensive source of care. It is billed alongside a standard office visit code (99202 through 99205) and cannot be billed on its own.

✓ G2211 Applies When

The provider is the patient's established, ongoing source of care — managing the patient's long-term health, not just resolving a single episode. The intent to maintain a continuing relationship must be documented.

✗ G2211 Does NOT Apply When

The visit is a one-time or acute-only encounter with no ongoing relationship planned. Preventive/wellness visits also do not qualify. Billing G2211 on these encounters triggers denials and potential recoupment.

Medicare coverage began in 2024. Commercial and Medicare Advantage coverage varies significantly by payer. Always verify your payer contracts before routine G2211 billing. CMS G2211 FAQ

ICD-10 Codes & Billing Modifiers

Every diagnosis code on a new patient claim must support the CPT code it is paired with. A mismatch between ICD-10 and CPT, such as billing 99204 on a visit documented with only a wellness code, triggers a medical necessity denial.

COMMON ICD-10 CODES & KEY BILLING MODIFIERS COMMON ICD-10 DIAGNOSES Z00.00 Wellness exam, no abnormal findings → Preventive code only Z00.01 Wellness exam, abnormal findings → Preventive + problem E/M + Mod 25 I10 Essential hypertension → Common new patient 99203–99204 E11.9 Type 2 diabetes, uncomplicated → Often supports 99204 (workup needed) Z00.129 Child routine exam, no abnormal findings → Preventive context, child age range KEY BILLING MODIFIERS -25 Significant, separate E/M same day Use when a problem visit occurs on same day as preventive or procedure -95 Synchronous telehealth (audio-video) Required for telehealth new patient visits -57 Decision for major surgery E/M that results in decision for major surgery -24 Unrelated E/M during global period Visit unrelated to prior surgery in global period

Common New Patient CPT Coding Errors

Most denial risk on new patient claims concentrates in a handful of recurring mistakes. Each one is predictable, and when denials do land, resolving them fast is what separates high-performing revenue cycles from struggling ones.

TOP 5 NEW PATIENT CODING ERRORS & FINANCIAL IMPACT 1 Patient Status Misclassification Billing new-patient codes for an established patient. Failed 3-year / same-specialty look-back. IMPACT: Recoupment 2 MDM vs. Time — No Method Documented Selecting 99204/99205 without specifying whether MDM or total time justified the level. IMPACT: Downcode on audit 3 Billing Consult Codes to Non-Accepting Payers Submitting 99242–99245 to CMS or payers who stopped recognizing them after 2010. IMPACT: Denial 4 G2211 Misuse — One-Time or Preventive Visits Appending G2211 to acute-only encounters or wellness visits with no longitudinal relationship. IMPACT: Denial / recoupment 5 Missing Modifier 25 on Same-Day Preventive + Problem Bundling a separately identifiable problem visit into a same-day preventive exam — losing the second service. IMPACT: Lost revenue

How Denials 360 Handles New Patient Claim Denials

When new patient claims are denied due to patient status misclassification, a disputed visit level, a missing modifier, or a payer policy mismatch, the cost is not just the denied dollar amount. It is the labor, the follow-up time, and the revenue sitting in your AR aging while your team works through the queue manually.

Denials 360 is DataRovers' AI-native, end-to-end denials management platform. It does not patch one step in the process. It manages the full denial lifecycle, from root cause identification through appeal and resolution.

$256M

In improper Medicare payments tied to new patient CPT coding errors — classification mistakes, level mismatches, and modifier gaps that become denied claims. Denials 360 identifies the root cause of every denial and prioritizes the ones worth fighting. CMS / AAPC

Denial Root Cause Intelligence

Every denied new patient claim is automatically mapped to its root cause, whether that is a patient status error, a visit level dispute, a missing modifier, or a payer policy mismatch. Your team resolves the right problem the first time and prevents the same denial from recurring.

Automated AR Prioritization

Denials 360 scores every denied claim by recovery probability, payer timeline, and dollar value. High-yield denials surface first so your team recovers more revenue per hour worked instead of working through queues by submission date.

Payer Pattern Detection

When a payer starts denying new patient visits at elevated rates due to patient status issues, documentation gaps, or policy changes, Denials 360 surfaces the pattern before it becomes a revenue trend rather than after it appears in a quarterly report.

Evidence-Based Appeal Drafting

Denials 360 generates payer-specific appeal letters with clinical documentation pulled directly from the patient record. This cuts appeal preparation time and improves overturn rates on new patient denials.

See Denials 360 in Action

Our team will walk you through how Denials 360 manages the full denial lifecycle, from root cause identification to appeal and resolution, for new patient claims and across your entire revenue cycle.

Book a Demo with DataRovers No commitment required · Personalized to your health system

Frequently Asked Questions

What is the CPT code for a new patient office visit?
New patient office visits are reported with CPT codes 99202 through 99205. The level is selected based on the complexity of medical decision-making or the total time spent on the date of service. The old 99201 code was deleted in 2021 — the range now starts at 99202.
Is CPT code 99201 still active?
No. The AMA deleted 99201 effective January 1, 2021, when the office and outpatient E/M guidelines were revised. Any claim submitted with 99201 will deny. The new patient range now starts at 99202 (straightforward MDM, 15–29 minutes).
How does the three-year rule work exactly?
A patient is "new" if no provider of the same specialty and subspecialty in the same group practice has rendered a professional service to that patient within the past three years. Three scenarios trip coders up: (1) same group, different specialty — still new; (2) different group, same specialty — always new; (3) diagnostic-only services (imaging, labs) with no face-to-face visit — still new. The face-to-face encounter is what creates the established relationship.
When should I use modifier 25 with a new patient visit?
Use modifier 25 on a problem-oriented E/M code (99202–99205) when a separately identifiable, significant problem visit occurs on the same day as a preventive medicine service (99381–99387) or a procedure. The modifier goes on the E/M code, not the preventive or procedure code. Without it, the payer will bundle the two services and pay only the higher of the two.
Can I bill G2211 with a new patient visit?
Yes — G2211 can be reported with 99202–99205 when the provider intends to establish an ongoing, longitudinal care relationship with the patient and that intent is documented. A one-time or episodic encounter with no planned continuing relationship does not qualify. Medicare began separately reimbursing G2211 in 2024; commercial and Medicare Advantage coverage varies significantly — always verify payer policy.
What causes new patient claims to be denied most often?
The top drivers are: (1) billing new-patient codes for established patients after a failed three-year lookback; (2) selecting a visit level (especially 99204 or 99205) without documenting whether MDM or total time justified it; (3) submitting consult codes (99242–99245) to payers who no longer accept them; (4) misusing G2211 on acute or wellness visits; and (5) omitting modifier 25 when a problem visit occurs alongside a same-day preventive exam. Denials 360 by DataRovers identifies the root cause of each denied claim and manages the full resolution workflow — from prioritization through appeal — so your team spends time on decisions, not queues.
Do consult codes work for new patients in 2026?
Consult codes 99242–99245 still exist in the CPT code set, but CMS eliminated Medicare reimbursement for them in 2010 and most commercial payers followed. In practice, the vast majority of new patient "consultation" encounters should be billed with standard office visit codes (99202–99205). Always verify your specific payer's current policy before billing a consult code. Code 99241 was deleted in 2023.
How does Denials 360 help with new patient claim denials?
Denials 360 is DataRovers' AI-native, end-to-end denials management platform. When a new patient claim is denied — whether for patient status, visit level, a missing modifier, or a payer policy issue — Denials 360 automatically identifies the root cause, scores the denial by recovery probability and dollar value, and routes it to the right workflow. It generates payer-specific appeal letters with clinical documentation from the patient record, tracks payer patterns in real time, and manages the full denial lifecycle so revenue cycle teams resolve more denials in less time.