Office or other outpatient visit, established patient, level 2
Audit Defense & Denial Intelligence
Research-based denial patterns from OrbDoc Bill Analyzer
1. Insufficient documentation for straightforward MDM
Common99212 requires straightforward medical decision-making or 10-19 minutes total time. Denials occur when documentation is too brief to support even this basic level.
Common Causes
- • No time documented and MDM elements missing
- • Assessment and plan missing or incomplete
- • Chief complaint only, no documented clinical work
Resolution Strategy
Add basic clinical documentation (chief complaint, assessment, plan) or time statement. Most appeals succeed with minimal documentation enhancement.
💬 Plain Language Explanation
What this means
This is a straightforward office visit for an established patient. Your doctor performed a basic examination and made simple medical decisions.
Why you might see this
This is a common code for routine follow-up visits with established patients. It's used when your visit was straightforward and didn't require complex evaluation or decision-making.
Common context
Used for established patients with simple, straightforward medical issues that don't require complex evaluation.
What to ask your provider
"'Was this a straightforward visit, or were there additional concerns that might justify a higher-level code?'"
Relative Value Units (RVUs)
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Clinical Information
When to Use
Established patient visit with straightforward medical decision-making or 10-19 minutes total time
Common Scenarios
Documentation Requirements
- Chief complaint and brief history
- Problem-focused exam (1 body area or system)
- Straightforward medical decision-making
- OR document 10-19 minutes total time with activities
Coding Guidelines
Common Modifiers
Bundling Rules
- Cannot bill with same-day preventive visit without modifier 25
- Subject to global surgical period restrictions
Exclusions
- Do not use for new patients
- Do not use if time <10 minutes (use 99211)
- Do not use if time ≥20 minutes (use 99213)
Coding Notes
Clinical scenarios
- Chief complaint and brief history
- Problem-focused exam (1 body area or system)
- Straightforward medical decision-making
- Chief complaint and brief history
- Problem-focused exam (1 body area or system)
- Straightforward medical decision-making
- Chief complaint and brief history
- Problem-focused exam (1 body area or system)
- Straightforward medical decision-making
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Code Details
Medicare Pricing
PFSRVU Breakdown
OPPS Details
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Frequently Asked Questions
CPT 99212 is the billing code for "Office or other outpatient visit, established patient, level 2". Established patient visit with straightforward medical decision-making or 10-19 minutes total time
Medicare pays approximately $54.99 for CPT 99212 (national average). Actual payment varies by geographic location due to GPCI adjustments. Hospital and commercial insurance rates are typically 2-4x higher than Medicare rates.
CPT 99212 has a total RVU of 1.56, broken down as: Work RVU 0.70, Practice Expense RVU 0.79, and Malpractice RVU 0.07. RVUs (Relative Value Units) determine Medicare reimbursement rates.
The most common denial reason for CPT 99212 is "Insufficient documentation for straightforward MDM". 99212 requires straightforward medical decision-making or 10-19 minutes total time. Denials occur when documentation is too brief to support even this basic level. Common causes include: No time documented and MDM elements missing; Assessment and plan missing or incomplete. Appeal success rate is approximately 70-80%.
Key documentation requirements for CPT 99212 include: Chief complaint and brief history; Problem-focused exam (1 body area or system); Straightforward medical decision-making; OR document 10-19 minutes total time with activities. Missing or incomplete documentation is a leading cause of claim denials for this code.
Bundling considerations for CPT 99212: Cannot bill with same-day preventive visit without modifier 25. Subject to global surgical period restrictions Use an NCCI bundling checker to verify specific code combinations before billing.
Common modifiers for CPT 99212 include: 25 (When E/M service separate from same-day procedure), 95 (Synchronous telehealth (audio-video)). Modifiers indicate special circumstances and can affect reimbursement or prevent claim denials.
The typical time requirement for CPT 99212 is 10-19 minutes total time on date of service. Time-based codes require documentation of the actual time spent providing the service.