The short version
- New patient codes are 99202 through 99205. A patient is new only if nobody of your specialty and subspecialty, in your group, has provided a face-to-face service in the past three years.
- Each level has two paths: medical decision making or total time on the date of service. Either one on its own. History and exam have not set the level since 2021.
- 2026 Medicare pays about $75, $118, $177, and $237 nationally for 99202 through 99205, non-facility, against a conversion factor of $33.40 for non-QP clinicians and $33.57 for QPs.
- Office consultation codes 99242 through 99245 carry status I in the 2026 fee schedule. Medicare does not pay them. A consult for a Medicare patient is billed as a new or established office visit.
- Office visits were exempt from the 2026 efficiency adjustment that cut work RVUs 2.5% across roughly 7,700 codes.
Who actually counts as a new patient
A new patient has not received a face-to-face professional service from you, or from another physician of the same specialty and subspecialty in the same group practice, within the past three years.
Four places that breaks in a specialty office:
Same group, different provider. Your new associate sees a patient your senior partner saw 18 months ago. Same group, same specialty. Established. The visit is a 99213 or 99214, not a new patient code.
Subspecialty can split it. If two clinicians in your group are enrolled under genuinely different specialty taxonomies, a patient can be new to one and established with the other. Payers verify that against enrollment records, not your letterhead.
Three years runs from the service date. Not the calendar year. A visit on March 2, 2023 keeps the patient established through March 1, 2026.
Any face-to-face professional service counts. Not just an office visit. A procedure, a hospital service, a same-specialty encounter anywhere in the group starts the clock.
Billing a new patient code for an established patient is a straight overpayment, and it is one of the easiest things for a payer to find. They hold the same claims history you do.
The four codes, side by side
99202 is straightforward MDM or 15 to 29 minutes. A single self-limited problem, nothing ordered, nothing prescribed. It is rarer than its usage suggests.
99203 is low MDM or 30 to 44 minutes. One stable chronic problem or two minor ones, limited data, low risk. This is the house default in most practices, and the default is usually a level too low.
99204 is moderate MDM or 45 to 59 minutes. Two of three grid columns at moderate. Prescription drug management alone sets the risk column, which is why most real first visits land here.
99205 is high MDM or 60 to 74 minutes. Severe exacerbation or a threat to life or bodily function, two of three data categories, or high risk such as intensive drug toxicity monitoring. A genuinely high bar.
| Level | New patient | Time (new) | MDM | 2026 new | Established | 2026 est. |
|---|---|---|---|---|---|---|
| 2 | 99202 | 15-29 min | Straightforward | ~$75 | 99212 | ~$59 |
| 3 | 99203 | 30-44 min | Low | ~$118 | 99213 | ~$95 |
| 4 | 99204 | 45-59 min | Moderate | ~$177 | 99214 | ~$136 |
| 5 | 99205 | 60-74 min | High | ~$237 | 99215 | ~$192 |
MDM or time, never both
Since 2021, history and exam are documented as medically appropriate and carry no scoring weight. The level comes from medical decision making or total time. You choose one path per visit and the other does not need to agree.
The MDM path runs on three columns — problems addressed, data reviewed, risk — and you need two of the three at the level you are billing. Not all three. That is the single most common misreading of the grid.
The time path is total time on the date of service: chart review before the visit, the visit itself, and the documentation, as long as all of it happens that day. It excludes staff time and excludes work finished the next morning. When you code on time, the ranges are strict — 44 minutes is a 99203 and 45 is a 99204.
Past 74 minutes you are into prolonged services, and Medicare and CPT disagree there. Medicare pays G2212 and not until 89 minutes; 99417 carries status I and is not paid at all. Most commercial payers follow CPT and take 99417 at 75 minutes.
Consults, referrals, and the codes that are not these
Office consultation codes 99242 through 99245 carry status I in the 2026 Medicare fee schedule, the same as every year since 2010. Medicare does not pay them. CPT deleted 99241 entirely in 2023. For a Medicare patient, a consultation is billed as an office visit — new or established, by the three-year rule, at the level the MDM or time supports.
Some commercial payers still accept consult codes, and a few pay them better. That is a payer-by-payer question, not a house rule, and it is worth confirming rather than assuming in either direction.
Two related points that catch specialty offices:
A referral is not a consult. A consult requires a request for opinion or advice from another clinician and a report back. When a patient is simply sent to you for management, that is a transfer of care and it is a plain office visit no matter which payer you are billing.
New to you is not the same as new to the group. Referrals arrive constantly in dermatology and plastics, and the referral itself says nothing about whether the patient is new under the three-year rule. Check the group’s history first.
Five mistakes that turn a clean new patient claim into a denial
- Billing a new patient code for someone a same-specialty partner saw within three years.
- Requiring all three MDM columns at the billed level. You need two.
- Defaulting to 99203 without running the grid. Most first visits support 99204.
- Billing 99242 through 99245 to Medicare. They are status I and will not pay.
- Missing modifier 25 when a biopsy, destruction, or injection happened at the same visit.
Frequently asked questions
What are the new patient CPT codes?
99202, 99203, 99204, and 99205 for office or other outpatient visits. Each level is supported by either medical decision making or total time on the date of service, and either path qualifies on its own.
Who counts as a new patient?
A patient who has not received a face-to-face professional service from you, or from another physician of the same specialty and subspecialty in the same group practice, within the past three years. Three years runs from the date of the last service, not the calendar year.
How much do new patient visits pay in 2026?
About $75 for 99202, $118 for 99203, $177 for 99204, and $237 for 99205 nationally under Medicare, non-facility, before locality adjustment. The 2026 conversion factor is $33.40 for clinicians who are not qualifying APM participants and $33.57 for those who are.
What is the difference between a new patient and an established patient visit?
The three-year rule and the code family. New patient visits use 99202 through 99205; established use 99211 through 99215. At every level the new patient code pays more, because more work goes into a first encounter. The gap runs roughly $16 to $45 per visit depending on level.
Does Medicare pay consultation codes 99242 through 99245?
No. They carry status I in the 2026 fee schedule and have not been payable by Medicare since 2010. Bill a Medicare consultation as a new or established office visit at the level the MDM or time supports. Some commercial payers still accept consult codes.
Can a patient be new to one doctor and established with a partner?
Yes, if the two clinicians are enrolled under genuinely different specialties or subspecialties. If they share a specialty and subspecialty within the same group, a patient seen by either one in the past three years is established with both.
Do history and exam still determine the level?
No. Since 2021 they are documented as medically appropriate and carry no scoring weight. The level comes from medical decision making or total time on the date of service.
Are new patient codes affected by the 2026 efficiency adjustment?
No. CMS exempted time-based services, including the E/M office visit family 99202 through 99215, from the 2.5% efficiency adjustment applied to roughly 7,700 other codes in 2026.
This article explains how these codes tend to get paid — it is not coding, billing, or legal advice. Some of the codes here are bundled into the main procedure, or fall into grey areas that vary by payer. Before billing anything in a grey area, confirm it with your own coding and compliance team and the current guidance from the American Academy of Dermatology (AAD), Medicare (CMS), and AMA CPT. When in doubt, don’t bill it.
