EVALUATION AND MANAGEMENT CODES MOST LIKELY TO BE
USED BY PSYCHIATRISTS AND OTHER APPROPRIATELY
LICENSED MENTAL HEALTH PROFESSIONALS
It is vital to read the explanatory notes in the CPT manual for an accurate understanding
of when each of these codes should be used.
Note: For each of the following codes it is noted that: “Counseling and/or
coordination of care with other providers or agencies is provided consistent with
the nature of the problem(s) and the patient’s and/or family’s needs.” As stated
earlier, when this counseling and coordination of care accounts for more than
50% of the time spent, the typical time given in the code descriptor may be used
for selecting the appropriate code rather than the other factors
Office or Other Outpatient Services
NEW PATIENT
99201—The three following components are required:
• Problem-focused history
• Problem-focused examination
• Medical decision making that is straightforward
Presenting problem(s): Self-limited or minor
Typical time: 10 minutes face-to-face with patient and/or family
99202—The three following components are required:
• Expanded problem-focused history
• Expanded problem-focused examination
• Medical decision making that is straightforward
Presenting problem(s): Low to moderate severity
Typical time: 20 minutes face-to-face with patient and/or family
99203—The three following components are required:
• Detailed history
• Detailed examination
• Medical decision making of low complexity
Presenting problem(s): Moderate severity
Typical time: 30 minutes face-to-face with patient and/or family
