What CPT codes are used for new patient visits in primary care?

New patient E/M codes are 99202-99205, selected based on medical decision making (MDM) complexity or total time. 99202 is straightforward MDM, 99203 is low complexity, 99204 is moderate complexity, and 99205 is high complexity. Time-based billing requires total time documentation including pre/post visit work.

What defines a 'new patient' for billing purposes?

A new patient is one who has not received professional services from the physician or another physician of the same specialty in the same group practice within the past 3 years. After 3 years without a visit, the patient reverts to new patient status.

What documentation is required for 99204 new patient visit?

99204 requires moderate complexity MDM with: moderate number/complexity of problems addressed, moderate data review (ordering/reviewing tests, requesting records, independent interpretation), OR moderate risk of complications. Alternatively, document 45-59 minutes total time with time-based billing.

How do I document medical decision making for new patient visits?

Document three MDM elements: 1) Number and complexity of problems addressed, 2) Amount and complexity of data reviewed/analyzed (labs, imaging, records), 3) Risk of complications, morbidity, or mortality. Two of three elements at the level billed determines the code.

Should I include preventive care in a new patient visit?

You can address preventive care gaps during a new patient visit. If substantial preventive services are provided (immunizations, comprehensive screening), consider billing both the E/M (99202-99205) and preventive visit (99381-99387) with modifier 25 on the problem-focused code.

Adult New Patient Visit Template - Free Medical Template

Primary Care — New Patient Visit Template

Primary Care Family Medicine Updated: 11/7/2025

The Adult New Patient Visit Template is a comprehensive documentation tool designed for family medicine physicians, internists, and primary care providers conducting initial patient evaluations. This template provides a structured approach to documenting the patient's complete medical history, comprehensive physical examination, problem list, assessment, and treatment plan. Ideal for establishing care with new patients, this template ensures thorough documentation that meets billing requirements for 99204-99205 CPT codes while capturing all essential clinical information. The template includes sections for chief complaint, history of present illness, past medical history, surgical history, family history, social history, medications, allergies, review of systems, physical examination by body system, assessment with ICD-10 diagnostic codes, and detailed treatment plans. This standardized format improves documentation efficiency, ensures regulatory compliance, and facilitates continuity of care for primary care practices, internal medicine clinics, and multi-specialty groups.

Chief Complaint

{Enter patient's primary concern}

History of Present Illness (HPI)

Onset, location, duration, characteristics, alleviating/aggravating factors, radiation, timing, severity. Relevant negatives/positives. Prior related evaluations or treatments.

Review of Systems (ROS)

General, HEENT, CV, Resp, GI, GU, MSK, Skin, Neuro, Psych, Endo, Heme/Allergy.

Past Medical, Surgical, Family, Social History

PMH/PSH, medications, allergies (drug/food/latex), family history, social history (tobacco, alcohol, substances, occupation, living situation).

Physical Exam

Vitals: BP, HR, RR, Temp, SpO2, BMI.
General, HEENT, Neck, CV, Resp, Abdomen, GU (as indicated), MSK, Neuro, Skin, Psych.

Assessment & Plan

1) Problem 1 — assessment with supporting data.

Orders/Tests:
Medications:
Patient education/counseling:
Follow-up:

2) Preventive care/gaps addressed.

Patient Education & Safety

Discussed diagnosis, warning signs, when to seek care, and follow-up plan. Patient verbalized understanding.

Signature

Provider Name, Credentials, Date/Time.

Primary Care — New Patient Visit Template

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