Pediatric Coding Alert

Question: Are new-patient office visit codes a step down from established-patient office visit codes? For instance, does a 99202’s requirements equal a 99213’s?

Georgia Subscriber

Answer: The descriptors for 99202 and 99213 include the same type of history and examination: expanded problem focused. New-patient code 99202 compared to established-patient code 99213 requires one level lower of medical decision making (MDM) (99213 requires low complexity MDM while 99202 requires straightforward MDM). Code 99202, however, requires three of three key components, where as 99213 requires two of three key components, as follows:

Code         History Type                                    Examination Type                 MDM Type          Requirements

99213 expanded problem focused              expanded problem focused        low complexity        2/3

99202 expanded problem focused              expanded problem focused        straightforward        3/3

You can use the step down history tool as an easy way to remember the key requirement differences between newand established-patient office visit codes. Remember, new codes 99201-99205 require the physician to meet three of the three key components, whereas established-patient codes 99212-99215 require two of the three listed key components.

Here’s how the step down applies to a level-four established patient office visit:

Code              History Type                      Examination Type                            MDM Type              Requirements

99214              detailed                                       detailed                             moderate complexity          2/3

99203              detailed                                    detailed                               low complexity                     3/3