🩺 CPT 99202: Office Visit - Established Patient - Low Complexity

Quick Reference

CPT Code: 99202
Status: Established Patient
Complexity Level: Low (Straightforward)
Category: Office/Outpatient E/M Services
Typical Time: 20-29 minutes
Effective Date: January 1, 2021 (Current Definition)

📋Short Description

CPT 99202 is an evaluation and management (E/M) code used for office or other outpatient visit services for an established patient with low complexity medical decision making. This code requires a brief history, brief examination, and straightforward medical decision making.

Full Description

Definition

99202 represents a low-complexity office visit for an established patient. “Established patient” means the provider has seen the patient within the past three years. This code is appropriate when the visit involves:

Limited or focused history of present illness (HPI)
Limited or focused review of systems (ROS)
Limited or no past medical/social/family history
Straightforward medical decision making (MDM)
Brief physical examination

Clinical Context

This is the lowest-level established patient office visit code. It is typically used for:

Follow-up visits for chronic conditions (stable, no new issues)
Minor acute problems (cold, minor rash, etc.)
Medication refills with minimal evaluation
Brief counseling or educational visits
Routine preventive care follow-ups with minimal findings

Key Distinctions

99201 vs 99202: 99201 is for new patients; 99202 is for established patients
99202 vs 99203: 99203 requires moderate MDM and more comprehensive history/exam
99202 vs 99213: Both are established patient codes, but 99202 is used in the office setting with low MDM; 99213 would have higher complexity

1995 vs 1997 Documentation Guidelines

Using 1995 Guidelines (Documentation-Based)

History:

Problem Focused (PF): Chief complaint and brief HPI (1-3 elements)
ROS: Problem pertinent (addressing chief complaint only)
PFSH: None required for new problems; update as appropriate

Physical Examination:

Problem Focused: Exam limited to affected area/body system

Medical Decision Making:

Straightforward: Self-limited/minor problems with stable chronic illness
Risk of complications/morbidity: Minimal
Number of diagnoses/management options: Minimal
Amount/complexity of data: Minimal

Using 1997 Guidelines (MDM-Based - PREFERRED for 99202)

History:

Problem Focused: Chief complaint and 1-3 HPI elements
ROS: Problem pertinent (1-9 systems)
PFSH: None required or problem-specific update

Physical Examination:

Problem Focused: Limited to 1-2 organ systems

Medical Decision Making:

Straightforward:
- Number of diagnoses/management options: Minimal (self-limited/minor)
- Amount/complexity of data reviewed: Minimal
- Risk: Minimal risk of significant morbidity/mortality

Key E/M Element: At least 2 of 3 History/Exam/MDM components at PF level = 99202

Medical Decision Making (MDM) - Low Complexity Indicators

Diagnoses and Management Options:

Self-limited or minor illness
Established problem with no changes in status
No new diagnostic workup required
Simple medication management (routine refill)

Amount and Complexity of Data Reviewed:

No review of records
No ordering of tests
Limited or no diagnostic procedures
Minimal review of existing data

Risk of Complications/Morbidity/Mortality:

Minimal risk
Stable chronic conditions
No acute complications
Low risk procedures or decisions

Examples of Low MDM:

“Patient here for cough × 3 days, likely viral URI. Reassurance provided. Continue supportive care.”
“Refill of atorvastatin 20 mg, patient doing well on current regimen.”
“Minor cut, cleaned and bandaged, tetanus current.”

RVU (Relative Value Unit) Information

Current RVU Values (2025 Medicare)

Component	Value
Work RVU	0.92
Practice Expense (PE) RVU	0.89
Malpractice (MP) RVU	0.06
Total RVU	1.87

Note: RVU values are updated annually by CMS. Check your payer for specific current values as they may vary slightly.

wRVU (Work RVU)

99202 wRVU: 0.92 - Represents the physician work/effort
Used to calculate physician compensation
Varies by specialty; values shown are Medicare baseline

Conversion Factor Context

2025 Medicare CF (approx): $33.35
Approximate Payment: 1.87 RVU × $33.35 CF =$ 62.36
Actual payment varies by payer, geographic adjustment (GPCI), and specialty

HCC (Hierarchical Condition Category) Information

HCC Relevance to 99202

CPT 99202 itself is not an HCC code. However, the diagnoses documented during the 99202 visit may trigger HCC codes for risk adjustment purposes in Medicare Advantage and other capitated/value-based plans.

Common Scenarios Where 99202 Visits May Capture HCCs

Example Scenarios:

Scenario	HCC Code	HCC Description
Follow-up for type 2 diabetes, controlled	HCC 19	Diabetes without complications
Established COPD visit, stable	HCC 111	Chronic obstructive pulmonary disease
Follow-up for hypertension, BP controlled	HCC 96	Hypertension, no complications
Patient with history of MI, stable	HCC 86	Acute myocardial infarction
Established heart failure visit	HCC 85	Chronic heart failure
CKD Stage 3, monitoring	HCC 134	Chronic kidney disease

Important Note on HCCs

HCCs are typically captured when diagnoses are documented as active/ongoing or treated/managed during the visit
A 99202 visit focusing only on an acute, minor complaint may not capture any HCCs even if the patient has chronic conditions
The visit MDM must reflect the chronic condition being actively managed to properly support HCC coding
Document thoroughly: If managing a chronic condition, ensure it’s documented in the assessment/plan, not just the history

Example Documentation That Captures HCC:

Assessment and Plan:
1. Type 2 diabetes mellitus, well-controlled - Continue metformin 500 mg BID, A1C goal <7%, patient counseled on diet/exercise
2. Acute viral pharyngitis - Supportive care, throat lozenges, fluids

In this example, both the diabetes (HCC 19) and acute pharyngitis are documented.

Typical CPT and ICD-10-CM Code Examples

Sample ICD-10-CM Codes Often Used with 99202

Acute Conditions (Chief Complaint):

ICD-10-CM	Description
J06.9	Acute upper respiratory infection, unspecified
J20.9	Acute bronchitis, unspecified
R06.02	Shortness of breath, exertional
L89.90	Unspecified pressure ulcer, site unspecified
M79.3	Myalgia
F41.1	Generalized anxiety disorder
E11.9	Type 2 diabetes mellitus without complications
I10	Essential (primary) hypertension
K21.9	Unspecified gastro-esophageal reflux disease

Established/Chronic Conditions (Secondary Diagnoses):

ICD-10-CM	Description
E11.9	Type 2 diabetes mellitus (stable, follow-up)
I10	Essential hypertension (controlled, routine follow-up)
E78.5	Lipidemia, unspecified
J44.9	Chronic obstructive pulmonary disease, unspecified
I50.9	Unspecified heart failure
E03.9	Hypothyroidism, unspecified

CPT Codes Commonly Used with 99202

CPT	Description	Typical Use
99202	Office visit, established patient, low complexity	Primary E/M code
96160	Administration of patient-focused health risk assessment instrument	Depression screening, etc.
90834	Psychotherapy (30 min)	If mental health counseling performed
G0438	Annual wellness visit	Preventive visit (may be combined)
71046	Chest X-ray, 2 views	If imaging ordered
81000	Urinalysis, non-automated	If lab ordered

Documentation Elements Required for 99202

Essential Components Checklist

History (Problem Focused):

Chief complaint (CC) stated
HPI: 1-3 elements (location, quality, severity, duration, timing, context, modifying factors, associated signs/symptoms)
ROS: Problem-pertinent (1-9 systems reviewed, typically just the system related to CC)
PFSH: May be minimal or updated from previous visit

Physical Examination (Problem Focused):

Exam focused on related body area(s) and systems
Vital signs documented
Relevant findings documented

Medical Decision Making (Straightforward):

Clear problem identification
Straightforward differential (minimal options)
Assessment and plan clearly documented
Minimal data review/ordering

Time (if used as tiebreaker):

Approximately 20-29 minutes

Sample Documentation Examples

Example 1: Acute Minor Illness

CC: Sore throat × 3 days

HPI: 35-year-old established patient with sore throat × 3 days. 
Denies fever. No cough. Pain is moderate, worse with swallowing.

ROS: Negative for fever, cough, dyspnea.

PFSH: Patient reports taking acetaminophen with some relief.

PE: Vital signs stable. Throat erythematous, no exudate noted. 
Neck supple, no lymphadenopathy.

Assessment:
1. Acute pharyngitis, likely viral

Plan:
1. Supportive care: rest, fluids, throat lozenges
2. Acetaminophen as needed
3. RTC if not improved in 5-7 days or if fever develops

MDM: Straightforward - self-limited viral illness
Time: 22 minutes

Example 2: Chronic Condition Follow-Up (Stable)

CC: Hypertension follow-up

HPI: 58-year-old established patient with history of hypertension 
returns for routine medication refill. Reports good adherence with 
amlodipine. Denies chest pain, dyspnea, or headaches. 
BP readings at home have been 120-130s/70-80s.

ROS: Negative for angina, palpitations, lower extremity edema.

PFSH: Lives with spouse, works as accountant, denies tobacco.

PE: Vital signs: BP 128/76 R, HR 72 regular, RR 16.
Lungs clear, heart regular rate and rhythm.

Assessment:
1. Essential hypertension - well controlled

Plan:
1. Continue amlodipine 5 mg daily
2. Continue home BP monitoring
3. Return in 3 months

MDM: Straightforward - established problem, stable, no changes
Time: 18 minutes

Example 3: Medication Refill with Minimal Evaluation

CC: Medication refill

HPI: 72-year-old established patient calls for refill of levothyroxine. 
Reports feeling well. No complaints. Last TSH checked 6 months ago, 
noted to be normal.

ROS: Denies weight changes, fatigue, cold intolerance.

PFSH: No new medications or allergies.

PE: Vital signs stable. General: well-appearing, alert.

Assessment:
1. Hypothyroidism - stable on current therapy

Plan:
1. Refill levothyroxine 75 mcg × 3 months
2. No labs needed at this time
3. Routine follow-up as needed

MDM: Straightforward - routine refill, established stable condition
Time: 10 minutes (note: code based on MDM/history/exam, not time alone)

Common Coding Pitfalls to Avoid

❌ Coding Too High (99203 vs 99202)

Avoid 99203 if:

History is brief and focused (not detailed/extended)
MDM remains straightforward (one self-limited problem)
No moderate complexity decision-making evident

Example of potential upcode error:

Patient presents with "Follow-up of hypertension and diabetes"
BUT only vital signs checked, no labs ordered, no medication changes, 
no complications noted = Still 99202, not 99203

❌ Coding Too Low (99202 vs 99213)

99202 requires office-based setting. If this is a telehealth or other setting, verify appropriate code selection.

❌ Insufficient Documentation

Inadequate: “Patient seen for follow-up. Doing well.”
Better: “Patient seen for follow-up of Type 2 diabetes. Reports good adherence with metformin, no hypoglycemic episodes. A1C goal <7%. Continue current regimen.”

❌ Forgetting Time as Tiebreaker

If history and exam suggest 99202 but MDM suggests 99201, time can be the tiebreaker (20-29 min for 99202).

Quick Reference: 99202 vs 99203 vs 99213

Element	99202	99203	99213
Patient Status	Established	Established	Established
History	Problem Focused	Detailed	Detailed
Exam	Problem Focused	Detailed	Expanded
MDM	Straightforward	Low Moderate	Moderate
Time	20-29 min	30-39 min	20-29 min
Typical Setting	Office/Outpatient	Office/Outpatient	Office/Outpatient
Common Use	Minor acute, stable chronic	New problem, uncomplicated chronic	Complex chronic management

Payer-Specific Notes

Medicare

Global Package: Included in global surgical package post-op periods
Frequency: No specific frequency limitations
Documentation: Must meet 1995 or 1997 guidelines
Modifiers: -25 if separate from procedure same day (e.g., E/M + minor procedure)

Commercial Payers (Cigna, Aetna, UnitedHealth, BCBS, etc.)

Typically follow Medicare guidelines but verify specific payer policies
Some payers have stricter time requirements
May have bundling rules with telehealth codes

Medicaid (Wisconsin noted in your profile)

Wisconsin Medicaid follows CMS guidelines generally
Verify current fee schedule and any state-specific adjustments
Prior authorization requirements vary by program

Documentation Templates for Your Obsidian

Obsidian Frontmatter Example

---
cpt-code: 99202
title: "Office Visit - Established Patient - Low Complexity"
specialty: General
patient-status: Established
complexity: Low
typical-time: 20-29 minutes
mdm-level: Straightforward
last-updated: 2026-02-09
---

Quick Insert Template for Visit Notes

## CPT 99202 - Office Visit Note

**Patient:** [Name] | **DOB:** [Date] | **Status:** Established

**Chief Complaint:** 

**HPI:** 
- Location:
- Quality:
- Severity:
- Duration:
- Timing:
- Context:
- Modifying factors:
- Associated symptoms:

**ROS:** 

**PFSH:** 

**PE:**
- Vitals: BP: ___ HR: ___ RR: ___ T: ___
- [System exam findings]

**Assessment & Plan:**
1. [Diagnosis 1] - [Plan]
2. [Diagnosis 2] - [Plan]

**MDM Level:** Straightforward
- Diagnoses: Minimal
- Data: Minimal
- Risk: Minimal

**Time:** __ minutes
**CPT Code:** 99202
**ICD-10 Codes:** 
- [Primary diagnosis]
- [Secondary diagnosis (if applicable)]

Resources for Continued Learning

AAPC CPT Knowledge Base: Official CPT codebook updates
CMS MLN Connects: Medicare E/M documentation guidelines
Your Payer’s Coding Guidelines: Check Cigna, Aetna, UnitedHealth, BCBS-WI, UMR, Medicare websites
AHIMA Coding Standards: For inpatient coding correlations
Specialty-Specific Resources: If coding by specialty (urology, as you mentioned)

Notes for Your Workflow

This template is designed for quick reference during your workday. Consider:

Creating linked notes to related codes (99201, 99203, 99213)
Adding your payer-specific fee schedules as a separate note
Building a tagging system (#E/M, established-patient, low-complexity) for easy filtering
Using Obsidian’s template feature to generate visit note templates on demand

Last Updated: February 9, 2026
Next Review: When CMS updates RVU values (annually, typically November/December)

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99202