CPT® Code 99203

Quick Reference: CPT 99203

• Definition: New patient office or other outpatient evaluation and management (E/M) visit, per day.
• MDM Level: Low Complexity (e.g., 1 stable chronic illness, 1 acute uncomplicated illness, or 2+ self-limited problems).
• Time Threshold: 30 minutes or more of total time spent on the date of the encounter.
• Patient Status: New patient only — no professional service rendered by the same physician, same specialty, same group practice within the past 3 years.
• Setting: Office or other outpatient setting only. Not for hospital admissions, observation, or emergency department visits.
• 2026 Medicare National Rate: Approximately $115–$120 (non-facility). Verify exact rate via the CMS Physician Fee Schedule Look-Up Tool, as final 2026 rates reflect a +3.26% conversion factor increase.
• Key Exclusion: Do not bill 99203 for an established patient (use 99212–99215) or if the visit is straightforward and under 30 minutes (use 99202).

CPT 99203 represents the third level of the new patient office and outpatient evaluation and management (E/M) series (99202–99205). It is one of the most commonly billed codes in primary care and internal medicine, bridging the gap between the straightforward new patient encounter (99202) and the moderately complex one (99204).

Since the landmark 2021 AMA E/M revision — which eliminated the mandatory history and physical exam as code-level selection drivers — CPT 99203 is now selected based exclusively on Medical Decision Making (MDM) complexity or total time on the date of the encounter. These guidelines remain in full effect for 2026.

1. Code Definition & “New Patient” Rules

The official AMA descriptor for CPT 99203 is: “Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded.”

The phrase “medically appropriate history and/or examination” reflects the 2021 reform: a clinician must still gather history and perform an exam that is clinically appropriate for the patient’s presenting problem, but the detail and extent of that history or exam no longer determine the code level. Code selection is driven by MDM or time alone.

Who Is a “New Patient”?

A new patient is an individual who has not received any professional services from the physician (or another physician of the exact same specialty and subspecialty who belongs to the same group practice) within the past 3 years. This definition applies strictly — even if the patient is well-known to staff or has an existing chart from years prior, if the 3-year window has passed without a face-to-face professional service, the patient is considered new.

Critical Trap — The “Same Group, Same Specialty” Rule: If a patient sees Dr. A (Internal Medicine) in your group in January, then sees Dr. B (Internal Medicine, same group) in March, Dr. B must bill an established patient code (99212–99215), not a new patient code — even though Dr. B has never personally met the patient. The specialty and group affiliation, not the individual physician identity, governs the new-vs-established determination.

2. MDM Requirements and Time Criteria

Under the 2021–2026 E/M guidelines, code selection is driven by Medical Decision Making (MDM) OR total time. You only need to meet one of the two pathways, and you do not need to document history or physical exam to qualify for the level (though a clinically appropriate encounter must be documented).

flowchart TD
    A[New Patient Visit] --> B{Select Coding Pathway}
    B --> C[MDM Pathway]
    B --> D[Time Pathway]
    C --> E{Meet 2 of 3 MDM\nElements at Low?}
    E -->|Yes| F[Bill 99203]
    E -->|No - Higher| G{Elements at\nModerate or above?}
    G -->|Yes| H[Consider 99204/99205]
    G -->|No| I[Consider 99202]
    D --> J{Total physician time\non date of encounter?}
    J -->|30+ min| F
    J -->|15-29 min| K[Bill 99202]
    J -->|45+ min| L[Bill 99204]
    J -->|60+ min| M[Bill 99205]
    F --> N{Prescription written?}
    N -->|Yes| O[Upcode to 99204 -\nRisk = Moderate]
    N -->|No| P[99203 Confirmed]

A. Medical Decision Making (Low Complexity)

To bill 99203 by MDM, you must meet 2 of the 3 MDM elements at the Low level. This is the predominant method used in outpatient office settings:

• Element 1: Number & Complexity of Problems Addressed

2 or more self-limited or minor problems (e.g., upper respiratory infection + plantar wart).

• 1 stable chronic illness being managed (e.g., well-controlled hypertension on stable medication, stable hypothyroidism on levothyroxine).

• 1 acute uncomplicated illness or injury (e.g., sinusitis, UTI without systemic symptoms, ankle sprain).

• Note: The problem must be addressed at the encounter — a problem listed in a past medical history that is not evaluated, monitored, or managed does not count.

• Element 2: Amount & Complexity of Data (Must meet Limited threshold — at least 1 of the following)

Category 1 (Tests and Documents): Review of prior external notes OR order of a single test OR review of results of a single unique test (e.g., ordering a CBC, reviewing a chest X-ray report).

• Category 2 (Independent Interpretation): Independent interpretation of a test performed by another provider (e.g., reviewing the actual EKG tracing yourself, not just reading the cardiology note).
• Category 3 (Discussion with External Clinician): This qualifies at the Moderate data level and exceeds the Low threshold — using this category alone would bump the data element to Moderate.

Note: “Limited” data means meeting Category 1 or 2 criteria as described above. This element is often met simply by reviewing a prior lab result or ordering a test and noting your interpretation.

• Element 3: Risk of Complications and/or Morbidity or Mortality (Low Risk)

Management of over-the-counter (OTC) drug therapy (e.g., recommending ibuprofen, antacids, antihistamines).

• Minor surgery with no identified patient risk factors (e.g., uncomplicated excision or biopsy of a simple lesion).
• Occupational therapy, physical therapy, or speech therapy referral/order.
• Referral to a specialist without high-risk treatment decisions (e.g., referring a patient with stable knee pain to orthopedics).

Important: Low risk does not include prescription drug management — that jumps the risk level to Moderate, which would support 99204, not 99203.

The Prescription Drug Rule: The moment you prescribe, change, or discontinue a prescription drug, the Risk element escalates to Moderate, which supports CPT 99204 (not 99203). Many providers inadvertently undercode by billing 99203 when they have prescribed an antibiotic, a corticosteroid, or even a topical prescription-only cream. Always check: did I prescribe? If yes, your MDM risk is at least Moderate.

B. Total Time (30 Minutes)

If coding by time, you must document at least 30 minutes of total time on the date of the encounter. The 2024 CPT revision to the code descriptor confirmed that “30 minutes must be met or exceeded” — eliminating any ambiguity about the prior 30–44 minute range language.

What Counts Toward Total Time:

• Reviewing the chart, records, or prior test results before seeing the patient (pre-service time on the same date).
• Obtaining the patient’s history and performing the physical examination.
• Counseling the patient and/or family members directly.
• Ordering labs, imaging, or referrals.
• Documenting the note in the EHR (including after the visit on the same date).
• Coordination of care with other providers, including phone calls to consultants on the date of the visit.

What Does NOT Count:

• Time spent by nursing staff, medical assistants, or other clinical support personnel.
• Time spent on days other than the date of the visit (e.g., reviewing results two days later).
• Time documented in a way that is not attributable to the specific date of service.

Time Documentation Example: “Total time spent by me on the date of this encounter: 32 minutes, including pre-visit chart review, history and physical examination, patient counseling regarding lifestyle modifications, and documentation of this note.” This single sentence, added to the end of any note, is sufficient to establish the time basis for 99203.

3. Audit-Proof Documentation Standards

The 2021 reforms removed the need for “bullet counting” of history elements and physical exam findings. However, auditors now scrutinize MDM quality and completeness. Vague language is the #1 cause of downcoding on audit.

For MDM-Based Notes:

Additional Documentation Best Practices:

The chief complaint and history must be present and medically appropriate — even though they no longer drive the code level, their complete absence is a red flag in any audit and may prompt reviewers to question whether the visit occurred as billed. The physical examination findings should reflect the presenting problem (e.g., if evaluating a knee complaint, document knee exam findings). Always link the assessment and plan explicitly to the diagnosis codes billed — payers and MAC contractors increasingly use automated coding tools that look for diagnostic and therapeutic consistency.

4. Common ICD-10 Diagnosis Codes for CPT 99203

While CPT 99203 is diagnosis-agnostic (it is the visit level that determines the code, not the specific diagnosis), certain conditions routinely generate the documentation complexity and risk profile consistent with a low-complexity new patient encounter. Below are the most frequently paired ICD-10 codes:

ICD-10 Coding Tip — Specificity Matters: Payers often flag claims with unspecified diagnosis codes (e.g., R05.9 — Cough, unspecified) more than specific ones. Wherever the clinical documentation supports a more specific code, always assign it. For example, if the patient has allergic cough, use J30.9 rather than R05.9. Greater specificity also strengthens medical necessity arguments during audit.

5. Medicare Coverage, Reimbursement & RVUs

CPT 99203 is a payable Medicare Part B service when billed by a physician, nurse practitioner (NP), physician assistant (PA), or other qualified healthcare professional (QHP) in the office or other outpatient setting. As an E/M service, it is not subject to the –2.5% work RVU efficiency adjustment finalized by CMS for 2026 (that adjustment exclusively targeted non-time-based procedural and surgical codes).

2026 Reimbursement Overview

Note: Exact rates vary by geographic locality (GPCI). Use the CMS Physician Fee Schedule Look-Up Tool for your specific MAC and locality.

Medicare “New Patient” Verification

Before billing 99203 to Medicare, the provider must confirm there is no claim history showing a professional service from the same physician, same specialty, same group within the preceding 3 years. In practice, querying your EHR or Medicare beneficiary lookup tool before the appointment and documenting “Patient confirmed as new — no prior professional service within 3 years from this provider group” in the intake forms adds a layer of compliance protection.

Global Period Considerations

CPT 99203 carries a 0-day global period, meaning it does not initiate a surgical global bundle and does not restrict subsequent billing in the typical way that procedural codes do. This is relevant when, for example, a new patient is seen for evaluation on the same day that a minor procedure (such as a mole excision) is performed — both can be billed provided the appropriate modifier is appended.

6. Modifier Usage for CPT 99203

Modifier 25 — Significant, Separately Identifiable E/M Service

This is the most important modifier for CPT 99203. It is required when a new patient office visit is performed on the same day as a procedure or another E/M service, and the office visit represents a separate and distinct clinical service from the procedure. The E/M must be documented as having occurred independent of the pre-service evaluation required to perform the procedure.

Example: A new patient presents for an initial evaluation of a skin lesion. The physician takes a complete history, examines the lesion, documents low MDM, and then performs a shave biopsy (11305) during the same encounter. Billing: 99203-25 + 11305. The -25 certifies that the E/M was significant and separately identifiable from the minor procedure.

Modifier 25 Common Errors: You cannot append Modifier 25 simply because you want to bill both an E/M and a procedure. The E/M must address a clinically separate problem or represent a more extensive evaluation than is inherent to the procedure. If the sole reason for the new patient visit was to evaluate the lesion before excising it, many payers will deny the E/M as bundled into the procedure payment. Documentation must show a separate complaint or a level of history and decision-making that exceeds routine pre-procedure evaluation.

Modifier GC — Teaching Physician Service

Required when a teaching physician involves a resident in the new patient visit. It certifies that the teaching physician was present for the key (critical or representative) portion of the service — which for an E/M includes at minimum the history, physical exam, and the MDM portion. The teaching physician’s personal documentation in the note (not simply co-signing the resident’s note) is required to bill under Medicare Part B.

Modifier 95 — Synchronous Telemedicine Service

Append Modifier 95 to CPT 99203 when the visit is conducted via live, interactive audio-video telemedicine. Also assign the appropriate Place of Service (POS) code: POS 02 (telehealth, other than patient’s home) or POS 10 (telehealth, patient’s home). Medicare continues to reimburse telehealth E/M services at parity with in-person services for 2026, contingent on the patient and physician being in an eligible setting. Documentation must note that the service was conducted via telehealth and that interactive audio and video were used.

Modifier AT — Active Treatment (Chiropractic)

Chiropractors billing 99203 for new patient evaluation and management (distinct from chiropractic manipulative treatment) must append Modifier AT to certify that the service represents active treatment rather than maintenance care. This modifier is specific to Medicare billing and is required to avoid automatic claim denial for maintenance-level chiropractic services.

Modifier 32 — Mandated Service

Append Modifier 32 to 99203 when the new patient visit is court-ordered, mandated by a third-party payer, or required by a government agency (e.g., a workers’ compensation payer requires an independent evaluation). This does not change reimbursement but is important for compliance documentation.

7. Same-Day Preventive Visit Billing Rules

One of the most common and nuanced scenarios in office practice involves a new patient who schedules a preventive/annual wellness visit but presents with one or more acute or chronic problems that require separate E/M work. The AMA and CMS allow both the preventive visit and the problem-oriented E/M to be billed on the same day, but specific rules apply.

Correct Approach: Preventive Visit + 99203-25

When a new patient’s annual physical (e.g., 99385–99387 or G0439 for Medicare) is expanded because the physician also evaluates, assesses, and manages a separate acute or chronic problem:

• Bill the preventive visit code (e.g., 99385 for age 18–39).
• Bill 99203-25 for the separate, distinct problem-oriented E/M service.
• The separate E/M must be documented in the note as a distinct service with its own assessment and plan, not simply mentioned as part of the review of systems.

Medicare Annual Wellness Visit (AWV) Note: Medicare’s Annual Wellness Visit (G0402 — Welcome to Medicare; G0438/G0439 — AWV) is different from a preventive physical and has specific required components. A problem-oriented E/M can be billed in addition to the AWV using 99203-25, provided it is documented as a separately identifiable service. However, Medicare does not cover the routine preventive physical itself — the patient may owe cost-sharing for the 99203 component. Always advise patients about this potential balance before billing.

8. Detailed Comparison: 99202 vs 99203 vs 99204 vs 99205

9. Telehealth & Audio-Only Billing for CPT 99203

CPT 99203 is a covered Medicare telehealth service through at least December 31, 2026, under Congressional extensions of pandemic-era telehealth flexibilities. The MDM and time requirements are identical whether the visit is in person or via telehealth — there is no telehealth-specific alteration of the selection criteria.

Requirements for Telehealth Billing of 99203:

• The visit must be conducted via real-time, synchronous audio-video technology (for standard telehealth — Modifier 95, POS 02 or 10).
• Audio-only services using the legacy platform must use a different modifier (Modifier 93 with applicable HCPCS codes, though 99203 may also be reported with Modifier 93 in certain non-facility audio-only contexts — confirm with your MAC).
• State licensing and cross-state telehealth practice rules apply independently of CMS billing rules. Always confirm you are licensed in the state where the patient is physically located at the time of service.
• Place of Service code must match the technology used and the patient’s location: POS 10 (patient at home), POS 02 (patient at another facility).

10. Top Billing Errors & How to Avoid Them

Error 1: Billing 99203 for an Established Patient

This is the most frequent and costly audit finding. If the patient has been seen within 3 years in the same specialty/group, the correct codes are 99212–99215. Billing 99203 for an established patient constitutes a false claim and can trigger overpayment demands and, in intentional patterns, False Claims Act liability. Solution: Implement an EHR workflow that automatically flags established-vs-new status before the encounter.

Error 2: Billing 99203 Instead of 99204 When a Prescription Was Written

As discussed, any prescription drug management (starting, stopping, or adjusting a prescription medication) automatically elevates the Risk element to Moderate, supporting 99204. Providers who write a prescription for a new patient and bill 99203 are consistently downcoding — leaving significant reimbursement on the table while also creating documentation inconsistency. Solution: Add a prompt in your note template: “Did I write a prescription today? If yes, consider 99204.”

Error 3: Counting Nursing/MA Time Toward the 30-Minute Threshold

Only time personally spent by the billing provider (physician, NP, PA) on the date of service counts toward the time-based threshold. Rooming time, vital signs, and nurse assessments do not count. Solution: Train providers to start a personal time log from the moment they begin pre-visit chart review.

Error 4: Billing 99203 for a “New Patient” Who Had a Lab Review or Telephone Call Within 3 Years

A “professional service” that resets the new-patient clock must be a billable face-to-face service. Simple telephone calls without a corresponding E/M charge, or lab results reviewed by a covering physician who never documented a professional service, do not reset the new-patient clock. However, any billed telephone E/M (e.g., 99441-99443), portal message (99421-99423), or e-visit that was charged does count. Solution: Review billing history in your system — not just appointment records — before assigning new patient status.

Error 5: Failure to Append Modifier 25 When Performing a Same-Day Procedure

Omitting Modifier 25 when billing both 99203 and a procedure code on the same date is one of the most common claim denial triggers. Without Modifier 25, most payers will bundle (deny) the E/M and pay only for the procedure. Solution: Your practice management system should alert coders any time a procedure code and E/M code appear on the same claim for the same date.

Error 6: Misusing 99203 for an Emergency Department Visit

CPT 99203 applies only to office and outpatient settings. Emergency department visits for new patients are coded with the ED E/M codes (99281–99285), regardless of the patient’s history with the practice. Setting-of-service determines code family.

11. Complex Clinical Scenarios

Scenario 1: New Patient with Two Self-Limited Problems and Extended Counseling

Patient: 28-year-old new patient seen in a family medicine office for (1) URI symptoms for 5 days and (2) a plantar wart she wants evaluated. MDM Analysis: Two self-limited/minor problems (URI + wart) meets Element 1 at Low. Physician reviews prior PCP note from a prior group (external record) — meets Element 2 (Category 1 data review) at Limited. Counseling on OTC decongestant and saline nasal rinse; OTC salicylic acid for the wart — meets Element 3 at Low (OTC drug management). 2 of 3 MDM elements met at Low. Time: Visit took 34 minutes including pre-visit review and documentation. Coding: 99203 (MDM-based). Rationale: 2 self-limited problems + Limited data review + Low risk (OTC management) = Low MDM. Time (34 min) also independently supports 99203. ICD-10: J06.9 (URI) + B07.9 (Viral wart, unspecified).

Scenario 2: New Patient with Stable Hypertension — Prescription vs. No Prescription

Version A — No Prescription (99203): New patient with known HTN, currently on lisinopril (same dose for 2 years, prescribed by prior PCP). BP is 126/80 today. Physician reviews prior labs showing normal renal function. No medication changes. Referral to dietitian for DASH diet counseling. MDM: 1 stable chronic illness (Element 1, Low) + Limited data review of labs (Element 2, Limited) + Low risk (referral; no new prescription) = Low MDM → 99203. Version B — Prescription Change (99204): Same patient but BP is 158/94 today. Physician increases lisinopril from 10mg to 20mg and orders repeat BMP in 4 weeks. MDM: 1 chronic illness with mild exacerbation (Element 1, Moderate) + ordering a unique test (Element 2, Limited) + Prescription drug management (Element 3, Moderate) = Moderate MDM → 99204. Lesson: The prescription change is the single most important differentiating factor between 99203 and 99204 in a hypertension management scenario.

Scenario 3: New Patient Telehealth Visit for Allergic Rhinitis

Patient: 33-year-old new patient seen via video visit (Zoom for Healthcare) for seasonal nasal congestion, sneezing, and itchy eyes. No systemic symptoms. No known drug allergies. MDM: 1 acute uncomplicated illness — allergic rhinitis (Element 1, Low). No external data reviewed; problem-focused encounter (Element 2 — did not meet Limited; however, not required if Element 1 and 3 are both met). OTC loratadine 10mg recommended (Element 3, Low — OTC drug management). Time: 22 minutes total on date of service. Time alone does not meet the 30-minute threshold for 99203. MDM Coding: 2 of 3 MDM elements met at Low (Problem + Risk). Even without Element 2, Low MDM is met. → 99203-95 (with Modifier 95 for telemedicine) + POS 10 (patient’s home). Note: Because time is under 30 minutes, MDM must be used as the selection pathway. MDM correctly supports 99203 independently of time here.

Scenario 4: Preventive Exam + Acute Problem Same Day (Modifier 25)

Patient: 42-year-old new patient schedules annual physical. During the preventive history, patient mentions right knee pain for the past 3 weeks. The physician completes a full preventive examination (including age-appropriate preventive screening counseling), and then separately evaluates the knee (takes additional history, performs focused exam, reviews X-ray ordered today, recommends PT referral). Billing: 99385 (preventive, new patient, age 18–39 — if patient is 38) AND 99203-25 (problem-oriented E/M for knee pain, separately documented with its own A/P section). ICD-10: Z00.00 (annual exam) + M25.361 (pain in right knee). Note: The knee evaluation must be documented as a distinct section in the note with its own history, findings, assessment, and plan. Simply listing “knee pain — refer PT” in the review of systems or plan is insufficient to support a separately identifiable E/M.

Scenario 5: New Patient — Time-Based Coding with Complex Social Situation

Patient: 55-year-old new patient with obesity and fatigue. MDM on its face appears straightforward (1 chronic stable problem). However, physician spends significant time reviewing extensive prior records from multiple healthcare systems, counseling patient on metabolic syndrome, and coordinating with the practice’s registered dietitian and care management team on the date of service. Total time documented by physician on 02/11/2026: 47 minutes — including 12 min pre-visit chart review, 25 min face-to-face, 10 min post-visit documentation and care coordination calls. Coding: 47 minutes exceeds the 30-minute threshold for 99203, but also meets the 45-minute threshold for 99204. Because time governs selection, the correct code is 99204, not 99203 — illustrating that time-based billing can result in a higher-level code even when MDM alone would not have supported it. Lesson: Always consider whether time might justify a higher level than MDM, especially in visit types with extensive counseling, care coordination, or chart review of complex prior records.