New patient vs established patient CPT codes is a distinction billers get wrong constantly: 99202-99205 covers new patients, 99211-99215 covers established ones, with different rules and rates. The dividing line is whether the same physician, or a colleague of the same specialty in the group, has seen that patient in the past three years. Getting this wrong at intake is a fast way to trigger a denial, which is why patient eligibility verification matters as much as the coding itself.
What Makes a Patient “New” for CPT Coding Purposes?
A patient counts as new if they have not received a face-to-face professional service from that exact physician within the past three years. This also applies to another physician or qualified health care professional of the same specialty and subspecialty in the same group practice.
How Many Levels Do New and Established Patient Codes Have?
New patient visits use four levels, 99202 through 99205. Established patient visits use five levels, 99211 through 99215, because 99211 covers a minimal service that does not require MDM or a physician’s direct presence.
Do New and Established Patient Codes Pay the Same Amount?
No. At every matching complexity level, the new patient code pays more than the established patient code. That reflects the extra work of building a full history for someone the practice has not treated recently.
Can the Same Diagnosis Be Billed as Either New or Established?
No. The diagnosis has no bearing on the choice. Only the patient’s visit history with that physician or specialty group over the past three years determines which code family applies.
Key Takeaways
- New patient codes (99202-99205) apply only when no physician of the same specialty in the group has seen the patient in the past three years.
- Established patient codes (99211-99215) apply to everyone else, including a patient returning after a long gap if the same specialty group already treated them within three years.
- New patient visits pay more at every matching MDM or time level: 99205 reimburses $236.81 nationally versus $192.39 for 99215.
- 99211 has no new-patient equivalent, since it does not require MDM or a physician’s direct involvement.
- Both code families select a level by MDM or total time instead of history and exam bullet points, the same framework covered in CPT 99213 vs 99214.
- Misclassifying a returning patient as new is one of the most common triggers for an automatic claim denial.
What Are New Patient CPT Codes (99202-99205)?
New patient codes cover the first office or outpatient E/M visit for a patient the physician, or a same-specialty colleague in the same group, has not seen in the past three years. They run from 99202 (straightforward MDM, 15-29 minutes) to 99205 (high MDM, 60-74 minutes). They generally pay more than the equivalent established patient level, since the visit typically involves building a complete history from scratch.
What Are Established Patient CPT Codes (99211-99215)?
Established patient codes cover a return visit for a patient the same physician or specialty group has already treated within three years. They run from 99211, a minimal service reportable without a physician present, up to 99215, which requires high-complexity MDM or 40-54 minutes of total time. Established codes are billed far more often, since most office visits in an ongoing practice are follow-ups.
How Do New and Established Patient Codes Compare?
| Element | New Patient (99202-99205) | Established Patient (99211-99215) |
|---|---|---|
| Number of levels | 4 levels | 5 levels |
| Lowest code | 99202 ($75.15) | 99211 ($24.38) |
| Highest code | 99205 ($236.81) | 99215 ($192.39) |
| Lookback window | No E/M in past 3 years from same physician or same-specialty group member | Seen within the past 3 years by the physician or group |
| History/exam requirement | Medically appropriate, not separately leveled | Medically appropriate, not separately leveled |
Source: CY 2026 Medicare Physician Fee Schedule Final Rule, AUA E/M summary. National non-facility rates; local rates vary by geographic practice cost index.
New Patient vs Established Patient CPT Codes: 10 Key Differences
Ten practical dimensions drive how these two code families are used and paid, broken out below.
The Three-Year Lookback Rule
The test for “new” status is whether the exact physician, or another physician or qualified health care professional of the same specialty and subspecialty within the same group practice, has furnished a face-to-face service to that patient in the past three years. A patient who saw a different specialty within the same multi-specialty group is still new to this physician. A patient who saw a colleague of the identical specialty in the group is not.
Number of Code Levels
New patient visits have four levels (99202-99205). Established patient visits have five (99211-99215). The extra established-patient level, 99211, covers a minimal service, such as a blood pressure recheck by clinical staff, that does not require MDM or a physician’s direct presence. It has no new-patient counterpart.
MDM and Time Thresholds
Both families select a code level by MDM complexity or total time, but the time windows differ. New patient time ranges run in roughly 15-minute increments, from 15-29 minutes (99202) up to 60-74 minutes (99205). Established patient time ranges are tighter, from 10-19 minutes (99212) up to 40-54 minutes (99215), reflecting the shorter average length of a follow-up visit.
Reimbursement Gap at Matching Levels
New patient codes consistently pay more than their established patient equivalent. Under the 2026 Medicare Physician Fee Schedule, 99203 (low MDM) pays $117.57 versus $95.19 for 99213. 99204 (moderate MDM) pays $177.36 versus $135.61 for 99214. The gap reflects the additional practice expense of a first-time comprehensive workup.
Documentation Volume Expected
New patient visits typically require a fuller history: past medical, family, and social history, plus a medication reconciliation. A more complete exam is often part of it too, even though these elements are no longer separately scored for code level. Established patient documentation can focus more narrowly on what changed since the last visit, since baseline history is already on file.
Common Billing Errors by Category
The most common new-patient error is billing a returning patient as new after a gap of more than three years, without verifying whether a same-specialty colleague saw them sooner. The most common established-patient error is under-coding a visit that actually involved new problems or medication changes, simply because the patient is familiar to the practice.
Verification Workflow Before the Visit
Front-desk staff should check the practice management system for any prior visit to that physician’s specialty and subspecialty within three years, not just whether the patient has a chart on file. A chart existing in the system does not automatically make the patient established if the last visit predates the three-year window or was with a different specialty.
Impact on Scheduling and Visit Length
New patient appointments are typically scheduled for longer slots, since the higher-level codes assume 45 to 74 minutes of total time. Established patient slots are shorter by default, though a complex established patient visit can still justify 99214 or 99215 if the documented work supports it.
Group Practice and Specialty Nuances
In a multi-specialty group, the same patient can be simultaneously new to one specialty and established to another. A patient who has seen the group’s cardiologist for years but is visiting the group’s dermatologist for the first time is new to dermatology. This holds regardless of how long they have been a patient of the practice overall.
Audit Risk by Category
New patient codes draw scrutiny when a practice’s ratio of new-to-established visits runs consistently higher than its specialty peers, since that pattern can suggest misclassifying returning patients to capture the higher new-patient rate. Established patient codes draw scrutiny when a high proportion of visits are coded at 99214 or 99215 without matching documentation depth.
When to Use New Patient CPT Codes?
Use the 99202-99205 series when no physician or qualified health care professional of the same specialty and subspecialty in the practice’s group has furnished a face-to-face service to that patient in the past three years. This applies to a true first visit, a patient transferring from another practice, or a patient returning after a gap long enough to reset the three-year clock. It comes up especially often in dermatology, where referral-based intake makes new-patient visits common.
When to Use Established Patient CPT Codes?
Use the 99211-99215 series any time the same physician or a same-specialty colleague in the group has seen the patient face-to-face within the past three years, regardless of why the current visit is happening. Most visits in a primary care practice fall here, since ongoing chronic-disease management makes up the bulk of the schedule.
Best Practices for Billing New Patient CPT Codes
- Verify same-specialty visit history across the entire group, not just this specific physician’s own patient panel.
- Document the full history and reconciliation work performed, even though it no longer directly sets the code level.
- Confirm MDM or total time meets the selected level before defaulting to a higher code because the visit “felt” complex.
- Flag transferred patients clearly so front-desk staff apply the three-year rule correctly at scheduling.
- Recheck new-patient status if more than three years have passed since the last documented visit, even for a familiar name.
Best Practices for Billing Established Patient CPT Codes
- Resist defaulting to 99213 out of habit. Check whether the visit’s actual MDM supports 99214 or higher.
- Document what changed since the last visit rather than repeating the prior note’s assessment and plan verbatim.
- Confirm 99211 is used only for visits genuinely not requiring MDM or a physician’s direct involvement.
- Track the new-to-established visit ratio periodically to catch drift in either direction.
- Apply the same time-versus-MDM discipline used for new patient coding: pick one method and document it fully.
Mistakes to Avoid With New Patient CPT Codes
- Billing a patient as new when a same-specialty colleague in the group saw them within the past three years.
- Treating “new to this exact physician” as the test instead of “new to this specialty and subspecialty within the group.”
- Selecting a high-level new patient code based on visit length alone without documented MDM to match.
- Failing to verify a transferring patient’s most recent visit date with their prior practice.
- Assuming a first visit at a new practice location automatically resets new-patient status if the same group treated the patient elsewhere.
Mistakes to Avoid With Established Patient CPT Codes
- Billing 99211 for a visit that actually required physician-level MDM, which under-codes and under-pays the encounter.
- Copy-forwarding a prior note instead of documenting the current visit’s specific findings and decisions.
- Coding every follow-up at the same level regardless of what the visit actually involved.
- Missing that a patient has crossed back into new-patient territory after a three-year-plus gap in care.
- Mixing time-based and MDM-based criteria within the same claim instead of documenting one method fully.
Illustrative Documentation Example
The scenario below is a hypothetical example for teaching purposes, not an actual patient encounter.
A patient last seen by the practice’s cardiology group four years ago returns with new chest discomfort. Because the three-year window has lapsed, this visit is billed as new, likely 99204 if it involves moderate MDM such as ordering cardiac testing. Had the same patient returned two years after their last visit instead of four, the visit would be billed as established, most likely 99214 for comparable MDM.
Conclusion
The new-versus-established distinction is a scheduling and eligibility question first, and a coding question second. Get the three-year, same-specialty test right at intake, and the rest of the code selection follows the same MDM or time logic either way. Disciplined claims submission and processing is what usually catches a misclassified patient before a denial does.
FAQs
If a patient sees a nurse practitioner in the group, does that count toward the three-year rule?
Yes, if the nurse practitioner is of the same specialty and subspecialty designation as the billing physician and belongs to the same group practice. A visit with a qualified health care professional counts the same as a visit with a physician for this purpose.
Does an emergency department visit count as a prior professional service for new-patient purposes?
Generally no. Emergency department E/M services are typically excluded from the three-year lookback, since they are not considered an ongoing-care office visit with that specialty.
What happens if a new patient code gets billed for a patient who was actually established?
The payer typically denies or downcodes the claim once its own records show a prior visit within three years. The biller should verify the actual visit history and resubmit with the correct established patient code.
Can 99211 be billed without any physician involvement at all?
Yes, within limits. 99211 does not require a physician’s direct presence, but it still must be a medically necessary, physician-ordered service performed under general supervision, per the CMS Evaluation and Management Services Guide.
Does telehealth change whether a patient is new or established?
No. The new-versus-established test is based on the three-year, same-specialty visit history, not the modality of the visit. A telehealth visit counts the same as an in-person visit for this purpose; the place of service is reported separately, as covered in telehealth POS codes 02 vs 10.
