CPT Code 99212: Low-Complexity Established Patient Visits

What Is CPT Code 99212?

This code describes a short encounter, often related to a minor complaint, a single condition under control, or a routine service such as a medication check-in. The 2021 E/M guidelines allow it to be billed based on total time, which must be 10 to 19 minutes, or based on the level of medical decision-making.

It is one of the lowest-level E/M codes available for face-to-face visits and typically applies to simple follow-up care. It is important to remember that this code should not be used for new patient sessions.

When Should You Use 99212?

Use this code for visits involving limited or minimal issues. These might include reviewing a test result with no significant findings, confirming that a treatment plan is still appropriate, or managing a mild side effect.

While it is a low-paying code, using it appropriately can help reduce audit risk and support efficient care workflows. Avoid upcoding to higher levels unless truly supported by clinical data. Remember, honesty and integrity will keep you compliant and protected in the case of an audit. It will definitely pay off in the long run.

Why is code 99212 used only for established patients and not new patients?

The distinction between new and established patients exists because it is assumed that the provider already has existing knowledge of the patient’s history and prior records. 

New patient E/M codes like 99202 – 99205 require more comprehensive evaluation since no prior history is available.

Because a provider has no prior history with a new patient, it is assumed they have to do more investigation into underlying conditions in order to provide accurate medical services and diagnoses. 

Documentation Tips

Keep records clear and concise. Indicate the condition managed, actions taken, and any education or counseling provided. If billing based on time, be sure to include total time spent.

Reimbursement for 99212 ranges between $45 and $65, depending on payer contracts.

Always follow the 3-year lookback rule, which states “An established patient is one who has received professional services from the physician/qualified healthcare professional or another physician/qualified healthcare professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.” and ensure that its coded into your EHR and billing workflow.