cpt office visit follow up

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Office/Outpatient E/M Codes

2021 e/m office/outpatient visit cpt codes.

The tables below highlight the changes to the office/outpatient E/M code descriptors effective in 2021.

More details about these office/outpatient E/M changes can be found at CPT® Evaluation and Management (E/M) Office or Other Outpatient (99202-99215) and Prolonged Services (99354, 99355, 99356, 99XXX) Code and Guideline Changes.

All specific references to CPT codes and descriptions are © 2023 American Medical Association. All rights reserved. CPT and CodeManager are registered trademarks of the American Medical Association.

Download the Office E/M Coding Changes Guide (PDF)

List With CPT Codes For New Patient Office Visits | Short & Long Descriptions and Lay-Terms

4 CPT codes describe the procedures for a new patient office visit . These codes are used to record the level of complexity of the evaluation, management, and medical decision-making during the visit. You can find a complete list of office visits for both established patients and new patients here.

1. CPT Code 99202

Lay-term: CPT code 99202 is used when a healthcare provider performs an office visit for a new patient that requires a medically appropriate history and/or examination and straightforward medical decision making. The total time spent on the encounter must be 15 minutes or more.

Long description: Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 15 minutes must be met or exceeded.

Short description: New patient office visit, straightforward medical decision making, 15 minutes.

1.2. CPT Code 99203

Lay-term: CPT code 99203 is used when a healthcare provider performs an office visit for a new patient that requires a medically appropriate history and/or examination and a low level of medical decision making. The total time spent on the encounter must be 30 minutes or more.

Long description: Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded.

Short description: New patient office visit, low level medical decision making, 30 minutes.

1.3. CPT Code 99204

Lay-term: CPT code 99204 is used when a healthcare provider performs an office visit for a new patient that requires a medically appropriate history and/or examination and a moderate level of medical decision making. The total time spent on the encounter must be 45 minutes or more.

Long description: Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded.

Short description: New patient office visit, moderate level medical decision making, 45 minutes.

1.4. CPT Code 99205

Lay-term: CPT code 99205 is used when a healthcare provider performs an office visit for a new patient that requires a medically appropriate history and/or examination and a high level of medical decision making. The total time spent on the encounter must be 60 minutes or more.

Long description: Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 60 minutes must be met or exceeded.

Short description: New patient office visit, high level medical decision making, 60 minutes.

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What Are CPT Codes?

• Where Codes Are Used
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HCPCS Codes

Frequently asked questions.

Current Procedural Terminology (CPT) codes are numbers assigned to each task and service that you can get from a healthcare provider. For example, a routine check-up or a lab test has a code attached to it.

CPT codes are used to track and bill medical, surgical, and diagnostic services. Insurers use CPT codes to determine how much money to pay providers.

The same CPT codes are used by all providers and payers to make the billing process consistent and to help reduce errors.

This article will go over what CPT codes are used for and what problems you might encounter related to CPT codes on your medical or insurance records.

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A CPT code is usually a five-digit numeric code. However, some CPT codes are four numbers and one letter. A CPT code has no decimal points.

Some CPT codes are only used occasionally and some are not really used at all. Other CPT codes are used frequently. For example, 99213 and 99214 are codes for general office visits, usually to address one or more new concerns or complaints, or to follow up on one or more problems from a previous visit.

The American Medical Association (AMA) develops, maintains, and has copyrighted the CPT codes that are used today all over the world. These codes can change as healthcare changes, and new codes can be made and assigned to new services.

Current CPT codes can also be revised and unused codes thrown out. Thousands of CPT codes are used and updated every year.

Limitations of CPT Codes

While they are meant to help make the billing process in healthcare more uniform, the existence of CPT codes does not mean that everyone defines a healthcare service the same way.

CPT codes also do not ensure that different healthcare providers will get paid the same amount for the same service because payment is outlined in the contracts between providers and insurers.

For example, Healthcare Provider A may perform a physical check-up (99396) and be paid $100 by your insurance company. However, if you went to Healthcare Provider B, the payment for that same CPT code might only be $90.

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Types of CPT Codes

There are several categories of CPT codes:

• Category I: Procedures, services, devices, and drugs (including vaccines )
• Category II: Performance measures and quality of care (for example, patient follow-up)
• Category III: Services and procedures using emerging technology (these codes are usually temporary while the service or procedure is still fairly new)
• PLA codes: Used for lab testing

List of CPT codes

Here are some examples of CPT codes:

• 99214 can be used for an office visit
• 99397 can be used for a preventive exam if you are over age 65
• 90658 can be used for the administration of a flu shot
• 90716 can be used for the administration of the chickenpox vaccine (varicella)
• 12002 can be used when a healthcare provider stitches up a 1-inch cut on your arm
• 87635 can be used when you're given a COVID-19 test

Bundled Services

Bundled services are a single CPT code that describes several services that are performed together.

For example, if you break your arm and get an X-ray and a cast, these services might be bundled under one code for billing.

How CPT Codes Are Used

CPT codes directly affect how much a patient will pay for the medical care they receive.

Provider offices, hospitals, and other medical facilities are strict about how CPT coding is done. They hire professional medical coders or coding services to make sure that services are coded correctly.

Initial Coding

Your healthcare provider or their office staff will usually start the coding process.

If they use paper forms, they will list which CPT codes apply to your visit. If they use an electronic health record (EHR) during your visit, it will be noted in that system. These systems usually let staff call up codes based on the service name.

What’s the Difference Between a CPT Code and a ICD Code?

CPT codes have different uses than ICD codes . CPT codes identify the services provided to a patient, and ICD codes identify diagnoses. The CPT code system is managed by the American Medical Association, while the ICD code system is managed by the World Health Organization. 

Verification and Submission

After you leave the office, medical coders and billers examine your records. They make sure the correct CPT codes are assigned.

Next, the billing department submits a list of your services to your insurer or payer. Most healthcare providers store and transfer this information digitally, but some are still done by mail or fax.

Claim Processing

Your health plan or payer uses CPT codes to process the claim. They will decide how much to pay your provider and how much you will owe for the services that you got.

Health insurance companies and government officials use coding data to predict future health care costs for the patients in their systems.

State and federal government analysts use coding data to track trends in medical care. This information helps to plan and budget for Medicare and Medicaid.

Where You Will See CPT Codes

You'll see CPT codes in many different documents that you'll get as you move through the healthcare system.

Discharge Paperwork

When you are done with an appointment or are discharged from a healthcare facility, you will get some paperwork to take home with you. It usually includes a summary of the services you had, including the codes for those services.

The five-character codes are usually CPT codes. There are also other codes on that paperwork, like ICD codes that indicate a diagnosis (which may have numbers or letters, and usually decimal points).

When you get a medical bill, it will have a list of the services you received. Next to each service will be a five-digit code—usually, it's the CPT code.​

Explanation of Benefits

When you receive an explanation of benefits (EOB) from your payer, it will show how much of the cost of each service was paid on your behalf. Each service will be matched with a CPT code.

Matching CPT Codes to Services

If you're looking at your healthcare providers' and insurance billing process, you might want to know what all the codes mean.

However, CPT codes are copyrighted by the AMA and they charge a fee to use them. That means that you will not find a full list of CPT codes with explanations online for free.

That said, the AMA does provide consumers with a way to look up the CPT codes. Here's how to find out what a CPT code means:

• Do a CPT code search on the AMA website . You will have to register (for free). You are limited to five searches per day. You can search by a CPT code or use a keyword to see what the code for a service might be.
• Contact your healthcare provider's office and ask them to help you match the CPT codes and services.
• Contact your payer's billing department and ask them to help you with the CPT codes.

You can use the same steps to look up bundled codes.

Preventing Incorrect Coding

Understanding CPT codes can help you make sure that your hospital bill is correct and catch any billing errors—which do happen often. Some patient advocacy groups say that nearly 80% of bills for medical care contain minor errors.

These simple mistakes can have a big impact on your wallet. In fact, the wrong CPT code can mean that your insurance will not cover any of the costs.

Always review your bill carefully and compare it with your EOB to check for mistakes. It's not uncommon for healthcare providers or facilities to code for the wrong type of visit or service (typographical errors).

There are also fraudulent practices like "upcoding," which is when you are charged for a more expensive service than the one you got. On the other hand, "unbundling" is when bundled services or procedures are billed as separate charges.

If you come across something in your medical bill that doesn't add up, call your provider's office. It could be a simple mistake that the billing department can fix.

CPT codes are similar to codes from the Healthcare Common Procedure Coding System (HCPCS). If you use Medicare, you'll see HCPCS codes in your paperwork instead of CPT codes.

HCPCS codes are used and maintained by the Centers for Medicare & Medicaid Services (CMS). They are used to bill Medicare, Medicaid, and many other third-party payers.

HCPCS Code Levels

• Level I codes are based on CPT codes and are used for services and procedures that are offered by healthcare providers.
• Level II codes cover healthcare services and procedures that are not performed by healthcare providers.

HCPCS level II codes start with a letter and have four numbers. They may also have extra modifiers—either two letters or a letter and a number. Examples of items billed with level II codes are medical equipment, supplies, and ambulance services .

HCPCS level II code lists can be found on the CMS website . Level I codes, however, are copyrighted by the AMA just like CPT codes.

CPT codes are combinations of letters and numbers that match up with healthcare services and supplies. The AMA developed CPT codes to make sure that all healthcare providers have a uniform system for reporting the services they give to patients.

When you visit a healthcare facility, your provider uses CPT codes to let your insurer or payer know which services you got from them. The insurer or payer then reimburses the provider based on the CPT codes. You can see the codes on your discharge paperwork, bills, and benefit statements.

It's a good idea to check the codes when you receive a bill or statement. Your provider or the coder can sometimes make errors and if they're not fixed, you could pay more than you should have to.

Healthcare Common Procedure Coding System (HCPCS) codes are used by the Centers for Medicare and Medicaid Services (CMS) to bill Medicare, Medicaid, and other third-party payers.

HCPCS codes are separated into two levels of codes:

• Level I: Based on CPT codes, these are used for services or procedures often provided by healthcare providers.
• Level II: These codes cover health care services or procedures that healthcare providers do not offer. Examples include medical equipment, supplies, and ambulance services.

An encounter form keeps track of the diagnosis and procedure codes that are recorded when a patient visits a provider's office. The purpose of the form is to make sure the billing is correct and a receipt can be offered to the patient after the visit.

The six sections of CPT codes are Evaluation and Management, Anesthesia, Surgery, Radiology, Pathology and Laboratory, and Medicine. Each of the six sections also has sections within it that offer more detail about services.

Some of the most frequently used CPT codes are:

99201-05 (New Patient Office Visit)

99211-15 (Established Patient Office Visit)

99221-23 (Initial Hospital Care for New or Established Patient)

99231-23 (Subsequent Hospital Care)

99281-85: (Emergency Department Visits)

9241-45 (Office Consultations)

The CPT codes are currently used in over 60 countries.

American Medical Association. CPT® purpose & mission .

American Medical Association. CPT® overview and code approval .

American Medical Association. New CPT code for COVID-19 testing: What you should know .

Centers for Disease Control and Prevention. International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Clinical Modification (ICD-10-CM) .

Kaiser Family Foundation.  Studies find high rates of errors on medical billing .

Centers for Medicare & Medicaid Services. HCPCS coding questions .

American Association of Professional Coders. What is CPT ® ?

Meditec. Commonly used CPT codes in medical coding .

American Medical Association. CPT international .

By Trisha Torrey  Trisha Torrey is a patient empowerment and advocacy consultant. She has written several books about patient advocacy and how to best navigate the healthcare system. 

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Coding FAQ: Patient office visits

Question: How do I code for a patient office visit? Can I use consultation codes? What diagnosis code is appropriate for a patient office visit during which the patient is evaluated for OSA and scheduled for testing?

Answer: Patient visits are billed using evaluation and management (E/M) codes. The E/M codes are found in the CPT® code book. Office visits in particular are billed using two code ranges – for new patients, E/M codes 99201-99205 can be used; for established patients, E/M codes 99211-99215 can be used. Medicare no longer reimburses for consultation codes (E/M code range 99241-99245). However, some private payers may still reimburse for these services. Physicians should bill diagnosis code(s) that justify the service. In the case of an office visit, this may include hypersomnolence, snoring, obesity, or a range of complicating comorbidities such as hypertension. Unless the patient has been diagnosed with obstructive sleep apnea (OSA) previously, the diagnosis of OSA can’t be assigned until testing and interpretation is complete.

These recommendations may change, however, given the CMS Proposed Rule , in which CMS outlined plans to significantly modify E/M documentation guidelines, coding, and reimbursement, to align with the Patients over Paperwork initiative.  The AASM expressed support for the American Medical Association’s response to CMS , which encouraged the Agency to allow the medical community to assist with revising the E/M process through the formation of a workgroup, made up of health care professionals with experience in coding, reimbursement, and clinical expertise.  The Workgroup has since been convened and is working to identify solutions to the current E/M coding and payment issues and provide solutions for implementation in the 2020 calendar year.

If the coding recommendations change, an updated response to this coding question will be featured and posted to the AASM website.

In the meantime, please send any questions to [email protected] . Read more  Coding FAQs .

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Tips for using total time to code E/M office visits in 2021

Editor's note: In its 2021 Medicare Physician Fee Schedule, the Centers for Medicare & Medicaid Services (CMS) released new guidance regarding coding for prolonged E/M services. This article has been updated accordingly.

Outpatient E/M coding and documentation reforms that take effect Jan. 1 will allow physicians and other qualified health professionals (QHPs) to code office visits based solely on total time.

It pays to get familiar with the following table before then, and it may be worthwhile to attach it to your monitor or place it on your desk.

All times in minutes

For longer visits there is a prolonged visit code, 99417, that should be reported with 99205/99215 for every 15 minutes that total time exceeds the ranges for those codes. CMS, however, has decided to allow physicians and other qualified health care professional to bill for prolonged services only when they have exceeded the maximum time for a Level 5 visit by 15 minutes or more (at least 69 minutes for an established patient and 89 minutes for a new patient), rather than the minimum time. Because of the discrepancy, Medicare has its own code, G2212, for reporting prolonged services.   

Total time includes all of the time the physician or QHP spend on that visit on the date of service. That means it includes prepping for the visit (e.g. chart review) and anything done after the visit (e.g. calling other clinicians and ordering tests or procedures) after the face-to-face portion of the visit. But it does not include staff time or time spent by the physician or QHP outside the date of the visit. Here are some tips for coding based on time, and an office visit example.

Time tracking tips

Delaying the completion of your notes is not usually recommended. But some cases lend themselves to this. If the record review will take extended period, it might be worthwhile to prioritize doing that work on the visit date, if that fits into your workflow. If you anticipate discussing a case with another clinician (or independently interpreting a test) and that time will change your visit level, it may be appropriate to delay signing off on that record.

Keeping track of time is burdensome, leading many of us to forego time-based codes. But those minutes can add up. Some EHRs have timers that automatically track when you’re logged in to a patient's chart, which is imperfect, but helpful. If your system has this feature, make sure the EHR chart is open while you’re reviewing records (and take some notes about that review in the chart) before the visit, and make sure it’s open during the visit as well.

It's also a lot easier if you have the chart open during phone calls. You can add notes during or right after the call summarizing your time and discussion. It is not reasonable to expect that you have a timer logging your every movement in case you need it for coding. Small increments (1-2 minutes) are difficult to track and often don’t’ seem worth the effort to keep up with, so admittedly are easy to "lose." But if you end up on a phone conversation without the EHR tracker going, it's often worth glancing at the call time on your phone and recording that time as well.

If you make a good faith estimate of the time spent on behalf of a patient on the date of the visit and it lands close to the point where it crosses over to the next level and a higher charge, I would err on the side of caution and choose the lower level. But unless you consistently and frequently code 99215 (time range 40-54 min) with an estimated total time of 40 minutes, this is not likely to be an issue.

Some common tasks may be physically impossible for you to complete in less than a certain amount of time, which makes it easier to record. For example, my state requires physicians to check the Prescription Drug Monitoring Program (PDMP) when we prescribe controlled substances. While it sometimes takes longer, this task is never less than two minutes for me. Other recurrent tasks that may have a specific "base time" for you might include specific types of phone calls (e.g. pharmacy), certain referral tasks, or specific documentation activities (e.g. Family Medical Leave Act paperwork).

Some things just don't lend themselves to time tracking, like results review. But if your total time is going up toward the threshold for a higher level visit, then by all means, add in that couple minutes.

A 76-year-old established patient with mild to moderate dementia, who lives in an assisted living facility, presents with confusion related to her medication regimen. She also has diabetes and hypertension. Pill counts are performed during the visit and records from an urgent care center are reviewed. The physician also reviews medication pick-up history with the pharmacist. In addition to periodic urgent care visits with medication changes, the physician discovers erratic refill patterns. The physician has a phone call with the patient’s family member who has power of attorney (POA) and helps with a pill planner. They discuss medication adjustments, and a plan to shift the patient’s medication administration to “supervised.”

Here's how the time for each activity could break down, and how the physician or QHP could track it.

You are not required to split out the total time into its various segments like this, but it may prove useful in the event of an audit. Some of the activities listed could be anticipated following the visit (e.g., the phone calls to the pharmacist and POA). It should be clear relatively early in this encounter that at least the 30-minute threshold for 99214 would be met, and so it would be worthwhile to start tracking the time.

Prior to 2021, only the face-to-face time with the patient can be considered for time-based coding. Using this example, that would be less than 18 minutes (assuming chart review was performed before the face-to-face time). Although the other activities are important, they cannot be counted toward “time” until the new rules take effect. Getting into the mindset that everything you do for that patient on that day "counts," as of Jan. 1, will make you better prepared to code using time, and more diligent about tracking those minutes.

— Samuel L. Church, MD, MPH, CPC, CRC, FAAFP
 Northeast Georgia Medical Center Family Medicine Residency, Core Faculty
 AAFP Advisor, AMA CPT Editorial Panel

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