99203

Office or other outpatient visit for the evaluation and management of a new patient, 30-44 minutes

CPT code 99203 is used for the initial evaluation and management of a new patient in an outpatient or office setting. By definition, a new patient is one who has not received any professional services from the physician or another physician of the same specialty and subspecialty who belongs to the same group practice within the past three years. According to the 2021 E/M documentation guideline revisions, the selection of this code level is primarily driven by either the level of Medical Decision Making (MDM) or the total time spent by the physician or qualified healthcare professional on the date of the encounter. For 99203, the MDM must be at a 'Low' level. This typically entails managing two or more self-limited or minor problems, one stable chronic illness, or one acute, uncomplicated illness or injury. The data reviewed is minimal to none, and the risk of complications from treatment or further diagnostic testing is low. Alternatively, if the clinician chooses to bill based on time, the total time spent on the day of the encounter must fall between 30 and 44 minutes. This total time includes both face-to-face time with the patient and non-face-to-face work such as reviewing external records, communicating with other professionals, and documenting the visit in the electronic health record. Although a medically appropriate history and physical examination are required components of the visit, the specific elements of those sections no longer determine the level of service.

Clinical Indications

  • Initial evaluation of a patient presenting with an uncomplicated acute illness such as pharyngitis or sinusitis.
  • Evaluation of a new patient with a stable chronic condition like well-controlled hypertension.
  • Initial assessment of a minor musculoskeletal injury, such as a simple ankle sprain without suspected fracture.
  • New patient consultation for a specific self-limited symptom like a localized skin rash.
  • Comprehensive intake for a patient establishing care for general health maintenance without high-risk comorbidities.

Procedure Steps

  1. Preparation: Review of the patient's intake forms, medical history, and any available external records before the encounter.
  2. History Acquisition: Conduct a medically appropriate history including the chief complaint, history of present illness, and relevant social/family history.
  3. Physical Examination: Perform a medically appropriate physical examination based on the patient's symptoms and clinical judgment.
  4. Assessment: Evaluate the clinical findings to determine a diagnosis or list of differential diagnoses.
  5. Management Plan: Develop a treatment plan, which may include prescribing a single medication, ordering routine lab work, or providing home care instructions.
  6. Counseling: Discuss the diagnosis, risks, and benefits of treatment options with the patient or their caregiver.
  7. Documentation: Finalize the medical record, ensuring all time spent or MDM components are clearly captured for the date of service.

Coding Guidelines

  • Verify 'New Patient' status: No services from the same specialty/group in the prior 36 months.
  • Code selection is based on either the Medical Decision Making (Low level) or Total Time (30-44 minutes).
  • If using time, include all activities performed on the date of encounter, excluding time spent on separately billable procedures.
  • Do not report 99203 in conjunction with other E/M services for the same patient on the same day by the same provider.
  • A medically appropriate history and/or examination must be performed and documented, but the extent is at the discretion of the clinician.
  • Ensure that the documentation supports the 'Low' complexity of the MDM if not billing by time.

Associated ICD-10 Codes