CPT 2026 Outpatient E/M Coding: New vs Established & Telemedicine

Hello friends, welcome back. Today we are going to learn evaluation and management outpatient services from CPT

2026. Let's take a quick look at our today's presentation agenda. First we will

understand office and outpatient ENM coding. Here we will learn how to determine patient is new or established.

Then tele medicine services. Then tele medicine modifiers and place of service codes. We will clarify how to correctly

pair tele medicine codes with the appropriate modifiers and place of service codes to prevent claim denials

and then finally we will solve few questions. Let's break down office and outpatient services. All of these visits

fall under the CPT code range 99202 through 99215. Here we have two code sets. For new

patients we have code range from 99202 to 99205 and for established patient we have code

range from 99211 to 99215. The very first thing you need to

determine is whether your patient is classified as new or established. Okay. So, a patient is considered new if

they have not received any professional services within the past 3 years from same provider or from another provider

of the exact same specialtity and subsp specialty within the same practice group. For example, patient came to

clinic on 14th September 2026 and previously he visited the same provider on 10th July 2023. Here the time span is

more than 3 years. So we considered this patient as new patient. Also if the patient is coming for the first time

then obviously he is considered as a new patient and a patient is established if they have received any professional

services within the past 3 years from same provider or from another provider of the exact same specialty and sub

specialty within the same practice group. Finally, look at the highlighted rule at the bottom. The rule is an ENM

code selection is based strictly on either medical decision making or the total time spent on the date of the

encounter. Remember history and physical exams are no longer used to select ENM good levels. I have already made video

on how to select ENM MDM level. If you have not seen that video, please click on the link given in the description.

Let's see the CPD codes for new and established patients. So, we have new patients on the left side. There are

four CPD codes 99202 to 99205 based on MDM and time. CPD code 99202 requires straightforward MDM or 15 to 29 minutes

of total time spent. CPD code 99203 represents low complexity MDM or 30 to 44 minutes. CPT code 99204

is for moderate MDM or 45 to 59 minutes total time spent. CPT code 99205 is for high complexity MDM or 60 to 74

minutes. For new patient use 99 417 once total time reaches 75 minutes or longer. On the right side we have

established patients and the code range is 99211 to 99215. Well, 99211 is unique as it requires no

physician or qualified health care professional presence such as a routine nurse visit for blood pressure check,

weight check or tracing change. 99212 requires straightforward MDM or 10 to 19 minutes total time spent. CPD code 99213

requires low level of MDM or 20 to 29 minutes spent. CPT code 99214 is for moderate MDM or 30 to 39 minutes and

99215 is for high complexity MDM or 40 to 54 minutes. For established patients use 99417

once the total times reaches 55 minutes or longer. Now let's look at the CPD course for tele medicine services. The

tele medicine code range shown here is 980 through 98016.

These codes are used when the service involves more than 10 minutes of medical discussion. First let's understand what

synchronous means. Synchronous means provider and the patient are communicating in real time. So both are

present at the same time during the encounter. For example, if the provider and the patient are having a live video

visit through a teley health platform that is synchronous audio video service. On the left side we have synchronous

audio video services. For a new patient we use codes 980 through 98003

and for established patient we use 98004 to 98007. On the right side we have synchronous

audio only services. These are realtime telephone or audio only encounters for new patients. The codes are 98008

to 9801 and for established patients 98012 to 98015

and uh then we have one code 98016 which is used for a brief synchronous communication technology based service

such as virtual check-in. If the medical discussion is 5 to 10 minutes then you can report CPT code 98016

but first check the payer guidelines before you report this code. Finally just like other ENM services the ENM

code selection is based on either MDM or time. So here one thing to remember is synchronous means realtime communication

and then we determine whether the service was audio video or audio only and also whether the patient is new or

established. All right. So we have seen the tele medicine CPT scores. Now let's talk

about tele medicine modifiers and place of service because these are very important when coding teley health

services. First let's look at the modifiers. Modifier 95 is used for synchronous audio video services. In

simple terms, this means the provider and patient are communicating in real time using both audio and video.

Modifier 93 is for synchronous audio only services such as a telephone call or realtime audio communication. and

modifier GT is another modifier you may come across for interactive audio and video telecommunication systems

depending on the payer and applicable coding requirements. Now important thing is do not append these modifiers with

tele medicine CPD codes. Now let's move to place of service. Place of service two is used when teley health is

provided somewhere other than the patient's home. For example, the patient could be at another healthcare facility

or another location. Place of service stand is specifically used when the patient is located or patient is present

at the home during the teley health service. Now here is an important coding and behind tip for Medicare CPD codes

980 to 98015 are not reimbured. Instead for

applicable Medicare teley health visits, you would use CPT 9992029215 office visits code along with the

appropriate modifier and place of service. On the other hand, commercial payers and medicaid payers may accept

CPT 980 to 98015. Okay? So, you should not report any teley health modifier with the CPD

course. All right? So, don't apply one teley health coding rule to every payer. Always check the specific payers policy

for the course modifiers and POSOS before submit the claim. Let's solve some questions. A

68-year-old established patient presents to the outpatient clinic for a followup on multiple chronic conditions. The

physician documents spending a total of 58 minutes of provider time on the date of the encounter, reviewing records,

examining the patient, counseling on medication management, and finalizing notes in the EHR. He also documents the

label of care is moderate. Which of the following CPD code combinations should be reported for this encounter?

Let's look at the keywords. So this is an established patient total time spent is 58 minutes and provider also

documents that this is moderate level of care. Okay. As per time spent we should code for 99215

and as per MDM we should code for 99214. You must be confused right? Well, let's remember the coding rule for selecting

ENM label we learned in our last ENM video. And what is that rule? When coding an office visit, you can select

the final ENM code using either MDM or total rank spent whichever results in the higher here. Which one is the

highest level? High MDM, right? So we are considering 99215 for this service. Now let's eliminate option B

and option C. Now we left with two options. Remember few minutes ago we have seen that

we report 99215 for maximum 54 minutes. Beyond 54 minutes, we must report outpatient

prolonged service CPD code 99417 along with 99215. All right. Now we have our correct

answer option D. Let's see one question regarding tele medicine guideline. An established

45-year-old patient initiates a 7-minute telephone conversation with their primary care physician to discuss a mild

skin rash. The physician provides medical advice, determines that a full evaluation is unnecessary at this time

and documents the interaction. The patient has not had an ENM service within the past 7 days and no follow-up

encounter is scheduled within the next 24 hours. Which CPT code should be reported for this service?

Here the patient is established. Also, this is 7 minute telephone conversation. If you see the options and descriptions,

CPT 9804 is for audio video and time spent must be 10 minutes. Option B, CPD 98012

is for only audio visit but time spent must be 10 minutes and option D 99212 is for face-to-face outpatient visit. So we

are going to eliminate option A, B and option D. Now we are left with only one option and

the description is saying that report this code for brief communication virtual check-in when done by physician

or qualified healthcare professional and it cannot originate from a related ENM service provided within the previous 7

days or lead to an ENM service procedure within the next 24 hours. And this CPD is for 5 to 10 minutes.

So the correct answer is option C 98016. I hope you understand this concept. Don't confuse friends. Just follow the

guidelines and you will definitely reach to the correct answer. Subscribe this channel for such easy to understand

concepts and thank you for watching the video.