When caring for new patients, practitioners use CPT codes 99202 through 99205 to report office evaluation and management (E/M) services. These codes are assigned based solely on Medical Decision Making (MDM) complexity—not by time thresholds. Here's a clear breakdown:

MDM-Based Code Differentiation

The AMA's MDM grid defines each code based on:

• Number and Complexity of Problems Addressed
  
  
• Amount and/or Complexity of Data to be Reviewed and Analyzed
  
  
• Risk of Complications and/or Morbidity or Mortality of Patient Management

Here's how they compare:

CPT Code

Problem Complexity

Data Review Complexity

Risk Level

Description

99202

Straightforward (e.g. single self‑limited/minor issue)

Minimal or none

Minimal risk

Basic new-patient visit

99203

Low (e.g. multiple minor problems, stable chronic illness, simple acute illness/injury)

Limited (review/order tests, etc.)

Low risk

Modest complexity

99204

Moderate (e.g. exacerbation of chronic illness, new undiagnosed problem, systemic symptoms)

Moderate (3 of tests/orders/review+independent historian, interpretation, or discussion)

Moderate risk

Intermediate care

99205

High (e.g. life‑threatening or severe acute/chronic problems)

Extensive (2 of 3: tests/documents/historian + independent interpretation + discussion)

High risk

Complex, high-stakes encounter

What You Can and Cannot Include Regarding Time

The Do’s:

• Document time when time is being used to determine medical necessity, such as prolonged services, but this does not affect code level for new patient E/M—those are based solely on MDM.
  
  
• Use time documentation as supportive information, e.g., "I spent 40 minutes counseling the patient..."
  
  

The Don’ts:

• Don’t use total time spent to select among 99202–99205. Time is no longer a factor for determining these codes under the 2021 guidelines.
  
  
• Don’t rely on time-based thresholds to justify higher-level E/M codes. Payers now expect documentation aligned with MDM elements.
  
  

Why 99204 Is the Most Common and the Documentation Caveat

In practice, 99204 is frequently billed for new-patient visits. Why?

• It reflects an ideal middle ground—moderate MDM complexity, covering typical primary care scenarios (e.g., reviewing multiple issues, moderate data analysis, and moderate risk decisions like prescribing medication or adjusting treatment).
  
  
• It balances clinical nuance with reasonable documentation effort.
  
  

Understanding why 99204 is so widely used helps providers make informed coding decisions that reflect the true complexity of the visit while avoiding undercoding or overcoding. It also highlights that while 99204 is common, appropriate documentation is crucial to justify its use and avoid compliance issues or denials.

remember, documentation must support the chosen code. With insurers implementing stricter audits, well-supported charts are essential.

Cigna’s New Policy (Effective October 1, 2025)

Cigna Healthcare will launch a program called “Evaluation and Management Coding Accuracy (R49)”, targeting professional claims using CPT codes 99204–99205, 99214–99215, and 99244–99245. Starting October 1, 2025, they may perform periodic reviews and adjust reimbursement downward by one level if AMA E/M documentation guidelines are not met. Documentation may be requested, or providers may be removed from the program if recurring issues are found.

Even though 99204 is commonly used, documentation must clearly reflect moderate MDM. If not, Cigna may downgrade it to 99203 or lower—so accuracy matters.

‍Takeaways

• Know the MDM grid: 99202 through 99205 are defined by MDM (straightforward → high severity), not time.
  
  
• Use time wisely: Time documentation is supportive, not primary, for these codes.
  
  
• Document thoroughly: Ensure your chart includes:
  
  
  • Nature and number of problems
    
    
  • Data reviewed, tests ordered, independent historian, interpretation, etc.
    
    
  • Risk considerations
    
    

Final Thoughts

Assigning the correct E/M code for a new patient is more than ticking a box; it’s about ensuring your documentation accurately reflects the clinical complexity you navigate. With the updated AMA guidelines and evolving payer policies, the stakes for precise, thorough documentation have never been higher. Stay informed, document diligently, and let quality care—and quality records—guide your coding.

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