Primary Care CPT Codes: Evaluation & Management
Evaluation and Management (E&M) codes are the foundation of primary care billing. Since the AMA's 2021 guideline revision, providers pick their code level using either Medical Decision Making (MDM) or total time on the date of service. The old bullet-counting for history and exam is gone, which simplified coding and moved the audit battles to MDM documentation instead.
Reviewed by the ClinicsFlows editorial team · Updated July 15, 2026 · How we source this
Primary Care & Evaluation and Management CPT codes
New Patient, Straightforward MDM (15–29 min)
Lowest new patient E&M level. Straightforward medical decision making or 15–29 minutes total time.
New Patient, Low Complexity (30–44 min)
New patient visit with low medical decision making or 30–44 minutes total time.
New Patient, Moderate Complexity (45–59 min)
Moderate MDM or 45–59 minutes. Most common mid-level new patient code.
New Patient, High Complexity (60–74 min)
Highest new patient E&M level. High MDM or 60–74 minutes total time.
Established Patient, Minimal (nurse visit)
Does not require physician presence. Used for simple nurse-administered services or medication refills.
Established Patient, Straightforward (10–19 min)
Lowest-level established patient visit. Minimal MDM or 10–19 minutes.
Established Patient, Low Complexity (20–29 min)
Low MDM or 20–29 minutes. Stable chronic illness, minor acute problem.
Established Patient, Moderate-High (30–39 min)
Moderate-high MDM or 30–39 minutes. Most commonly billed established patient code.
Established Patient, High Complexity (40–54 min)
Highest established patient level. High MDM or 40–54 minutes.
Preventive Medicine, Established, 40–64 yrs
Annual wellness exam for established adult patients. Not covered by Medicare, which uses its own AWV codes.
Codes in blue have full detail pages with documentation requirements, billing mistakes, and FAQ.
Primary Care & Evaluation and Management billing notes
Pick the level by MDM or by total time, whichever tells the visit's story better. Since 2021 you don't need both, and history and exam bullets no longer set the level.
New patient codes (99202–99205) pay more than established ones, and payers enforce the three-year rule: a patient seen by anyone in your group and specialty within three years counts as established.
Preventive codes (99381–99397) and sick-visit E&M codes don't substitute for each other. Medicare adds a twist by skipping CPT preventive codes entirely: it pays G0438 and G0439 for wellness visits instead.
Billing a procedure and an E&M on the same day? The E&M needs modifier 25 and its own documentation showing it was a separately identifiable service, not just the pre-procedure check.
Total time counts everything the clinician did on the date of service: chart review, documenting, ordering tests, calls with other providers. The face-to-face minutes are only part of it.
Frequently asked questions about primary care & evaluation and management billing
What's the difference between 99213 and 99214?▼
One level of complexity, and real money: 99214 pays roughly 40% more. 99213 fits a stable chronic condition or a simple acute problem; 99214 needs moderate complexity, like a chronic condition that's worsening, a new problem needing workup, or prescription decisions with meaningful risk. By time, 99213 covers 20 to 29 minutes and 99214 covers 30 to 39.
Can I bill a preventive visit and a sick visit on the same day?▼
Yes, when the sick issue is significant and separately documented. Bill the preventive code plus the E&M with modifier 25 on the E&M. Expect some payers to pay both, some to reduce the second, and patients to be surprised by the extra copay, so a heads-up at checkout helps.
Why doesn't Medicare pay 99396 or 99397?▼
Medicare never adopted CPT's preventive medicine codes. It pays for its own visits instead: the Welcome to Medicare visit (G0402) and the Annual Wellness Visit (G0438 for the first, G0439 after). Billing 99397 to Medicare gets a denial, not a reduced payment.
Sources
- Code set structure and updates: American Medical Association — CPT
- Fee schedule and component billing rules: CMS Medicare Physician Fee Schedule
- How we research and verify: our editorial policy
CPT® is a registered trademark of the American Medical Association. Content on this page is original educational writing, not a reproduction of AMA-copyrighted descriptions. Verify codes and payer rules before billing.