Medical billing CPT 99203


Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a detailed history; a detailed examination; and medical decision making of low complexity.

Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity.

Physicians typically spend 30 minutes face-to-face with the patient and/or family.

Average fee payment-$100  - $110

A 99203 is also called a Level 3 New Office Visit. What is it?

This office visit requires 3 key components

CPT 99203 can be used for 30 minutes spent face to face with the patient. This could be most common used for evaluation and treatment of new patients. Physician evaluate the patients on a regular basis, below documents are required for encounter. The appropriate documentation must be included.

1. A Detailed History
2. A Detailed Examination
3. Medical Decision making of LOW complexity

Why do I point out Low complexity? Because, I think we may actually be coding too much of these and may instead need to be coding more 99204s and 99202s....

Let's examine what the definition of "Detailed" is.
"Detailed History"-Requires a Chief Complaint (CC), "extended" HPI, problem pertinent Review of Systems (ROS) which is "extended" tp incude a limited review of:

A. Family History
B. Social History
C. Past Medical History 

All directly related to patient's problem.....

2. Detailed Examination-Requires an "Extended" examination of the affected body area or organ system AND other symptomatic or related organ systems.....

"Extended Examination"- requires 12 data points/bullets.

If you want to learn more about

3. Lastly, Medical Decision Making of "LOW COMPLEXITY"

Which requires
1. Limited number of Diagnoses or Management Options
2. Limited amount of data to review
3. Low complexity of data to review
4. Disease with low morbidity or mortality

So the question remains...."What does this look like?"

Initial offive visit for a 67 year old woman with hypertension, new to the area. She has had no problems with her BP while on a diuretic and home bp monitoring. She brings in her log.

So why do I think we are using this code too much? Here's the question.....would you do such a thorough History or Physical in a patient with well controlled HTN?

Patient 99395 99203 same day

When you see a new patient for the preventive visit, any other visit billed (that day, or from that point forward) is an established visit. Patients cannot be a new patient twice. 

Bill the 99385 with an established visit code, and with the -25 on the OV.
If a preventive medicine service and an office or other outpatient service are each provided during the same patient encounter, then it is appropriate to report both E/M services as new patient codes (ie, 99381-99387 and 99201-99205, as appropriate), provided the patient meets the requirements of a new patient based upon the previously noted guidelines. 

If, however, the acute visit (ie, office or other outpatient service, 99201-99215) is performed on a date subsequent to the new patient preventive medicine service and within 3 years, then it would be appropriate to report the established office or other outpatient visit code (ie, 99211-99215, as appropriate). 

Rationale Edit for E and M code 99201 - 99203, 99205

Anthem Central Region does not bundle 99201-99205, 97001 or 97003 with 97010-97546. When a patient is initially evaluated for physical or occupational therapy it is necessary for an evaluation and/or treatment plan to be developed to fit the medical/therapeutic needs of the patient. Based on the Correct Coding Edits Manual, codes 99201, 99202, 99203, 99204, 99204, 97001 or 97003 are not listed as component codes to codes 97010-97546.

Therefore, if 99201-99205, 97001 or 97003 is submitted with physical or occupational therapy modalities-- both the initial outpatient E/M service or the physical or occupational initial/evaluation and the physical or occupational therapy modalities reimburse separately.


Select the appropriate code based on the level of service provided when you are seeing a new patient for initial evaluation of a neuromusculoskeletal condition or injury.

Documentation in the clinical record must support the level of service as coded and billed. The Key Components - History, Examination, and Medical Decision Making - must be considered in determining the appropriate code (level of service) to be assigned for a given visit.

• Select code that best represents the services furnished during the visit.

• A billing specialist or alternate source may review the provider’s documented services before the claim is submitted to a payer.

• Reviewers may assist with selecting codes, however, it is the provider’s responsibility to ensure that the submitted claim accurately reflects the services provided.

• Ensure that medical record documentation supports the level of service reported to a payer.

• The volume of documentation does not determine which specific level of service is billed.

• Remember - medical necessity is the overarching criteria for coverage.

Note: for new patients, all three key components must meet or exceed the above requirements for a given level of service; for established patients, two of the three key components must meet or exceed the requirements.

General Information: The following paragraphs include general information about E&M procedures.

Levels of Care : Within each category and subcategory of E&M service, there are three to five levels of care available for billing purposes. These levels of care are not interchangeable among the different categories and subcategories of service. The components used to describe and define the various levels of care are listed in the “Evaluation and Management” section of the CPT-4 book.

Modifiers: Modifiers used to describe circumstances that modify a listed E&M code are listed with their descriptors in the Modifiers: Approved List and Modifiers Used With Procedure Codes sections of the appropriate Part 2 manual.

New Patient : A new patient is one who has not received any professional services. Reimbursement from the provider within the past three years. If a new patient visit has been paid, any subsequent claim for a new patient service by the same provider, for the same recipient received within three years will be paid at the level of the comparable established patient procedure.

RAD Reductions : The payment resulting from this change in the level of care will be made with a Remittance Advice Details (RAD) message defining the reduction as being in accordance with the service limit set for the procedure. These codes are listed in the Remittance Advice Details (RAD) Codes and Messages: 001 – 9999 sections in the Part 1 manual. Providers who consider the service appropriate and the reduction inappropriate should submit a Claims Inquiry Form (CIF).

Established Patient Reimbursement : An established patient is one who has received professional services from the provider within the past three years.

E&M Services Separately Reimbursable : The following CPT-4 codes for E&M services are separately reimbursable if billed by the same provider, for the same recipient and same date of service, and if the required documentation is included in the Remarks field (Box 80)/Reserved for Local Use field (Box 19) of the claim or on an attachment included with the claim.

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