Evaluation and Management (E/M) services remain an area of significant scrutiny in medical billing. The Office of Inspector General (OIG) states that nearly half of all payments under Medicare Part B are for E/M claims. Even with this large number, coding errors and discrepancies still led to $845 billion in changes to E/M claims and payments in 2017 alone.
Let’s dig a little deeper into understanding what the 99203 CPT Code covers. This guide offers in-depth insights on how to use CPT 99203 correctly under the American Medical Association CPT® 2026 and Centers for Medicare & Medicaid Services 2025 E/M rules. Using this code accurately can help providers document with precision, bill compliantly, and defend reimbursement with accuracy.
CPT Code 99203 Description
CPT Code 99203 represents an office or other outpatient visit for evaluation and management of a new patient. The patient might need a medically appropriate history and/or examination and a low level of medical decision-making (MDM). When the medical providers opt to use time as the basis for code selection to bill code 99203, the encounter must have a total of 30 to 44 minutes on the date of the encounter.
New Patient Definition:
A “new patient” is defined under the Centers for Medicare & Medicaid Services (CMS) as one who has not received professional services (for example, E/M services or other face-to-face services) from the same specialty within the same group practice during the past three years.
Evaluation and Management Code (E/M Code) & Medical Decision-Making (MDM)
Other outpatient E/M codes (99202-99215) allow for choice on the basis of either the medical decision-making (MDM) or total time spent on the date of the patient encounter.
Three elements define MDM:
- The number and complexity of problems addressed during the encounter.
- The amount of data to be accounted for and analyzed (for example, tests, records, and discussions with other professionals).
- The risk of morbidity, mortality, and complications is linked to the patient’s management.
In the case of CPT code 99203, the MDM must meet the low complexity standard. Based on the coding guidelines, it may include procedures like self-limited or minor problems, one stable chronic illness, or one acute illness/injury of low level of complication.
When to Use CPT 99203
Appropriate Use Cases
- New patient visit: CPT code 99203 can be used by the coders and providers for office or outpatient encounters that are for new patients. These patients have not been seen earlier by the same specialty group in the last three years.
- Clinical complexity: The encounter must have a need for a medically appropriate history and/or examination. It should also involve a low level of medical decision-making (MDM).
- Time-based coding: On the other hand, CPT code 99203 can be used when the encounter is recorded on the basis of timings that range from 30-44 minutes of the total time providers send to the patient. This may include both face-to-face and non-face-to-face activities.
Common Clinical Scenarios
- This code is used when there are two or more minor or self-limited problems (e.g., allergic rhinitis, tension headache).
- It can also be used in settings where there is one stable chronic condition that needs limited management (e.g., controlled hypertension follow-up for a new patient).
- It is also applicable when there is one acute, uncomplicated illness or injury (e.g., mild musculoskeletal strain).
When Not to Use 99203
- Straightforward MDM: CPT 92203 may be less suited for visits when decision-making is based on minimal data or risk (e.g., a single-problem visit is simple). Use CPT 99202 instead.
- Moderate or high MDM: Furthermore, this code should not be used when the visit entailed multiple comorbidities, diagnostic uncertainty, or risk from systemic symptoms; use CPT 99204 or higher instead.
Compliance Note
- Providers must ensure documentation clearly supports the method chosen (MDM or time).
- The presenting problems, data review, and risk must align with low-complexity MDM as defined by CMS and AMA CPT® 2026 standards.
CPT 99203 Billing Guidelines
Code Selection Requirements
- Adhere to AMA CPT® 2026 and CMS 2025 E/M coding standards to report CPT 99203.
- Code selection requires strong documentation attesting to the low-complexity MDM or time for the encounter.
- It is important to document a medically appropriate history and/or examination, all in relation to the presenting problem.
Modifier 25 Usage
- Modifier 25 may be appended to CPT 99203 when a significant and separately identifiable E/M service is rendered on the same day of a procedure.
- The E/M note must separately and adequately communicate that the provider performed additional work above and beyond normal pre- and post-procedure care.
- Remember to follow the NCCI policy to ensure that the notes are sequenced and to avoid bundling issues that lead to denials.
Medicare Billing Compliance
- Submit claims under the correct place of service (POS) and provider specialty.
- Ensure elements of documentation are supportive of the chosen E/M level for Medicare and commercial payers.
- Refer to the CMS Physician Fee Schedule (PFS) for reimbursement values and conversion factors.
Common Audit Triggers
- Improper application of the “new patient” definition (defined as seen by the same specialty within three years).
- Lack of MDM or time documentation to support CPT 99203.
- Misuse of Modifier 25 is simply incorrect or unnecessary.
- Lack of time documentation, as the total time or notes are not clear about the E/M time and procedural time.
Compliance Tip
- Prepare a specific, consistent documentation template that provides both clinical and coding integrity.
- Randomly audit internal claims samples to avoid RAC findings related to E/M level of care decisions or modifier misuse.
Documentation Requirements for CPT 99203
Efficient and complete documentation is a prime requirement to support CPT 99203 coding. The 2025 E/M revisions no longer mandate specific counts of history or exam elements for level selection. But the record must still reflect a medically fitting history and/or examination, and satisfy either the low-complexity MDM criteria or the time‐based threshold.
Chief Complaint (CC)
The chief complaint documents the patient’s presenting issue in their own words or the provider’s concise statement of the reason for the visit. It is the clinical anchor that guides the remainder of the visit documentation.
History of Present Illness (HPI)
The HPI outlines the development of the presenting problem, including onset, location, quality, severity, duration, modifying factors, and associated signs or symptoms as appropriate. The documented HPI must be aligned with the presenting problem and sufficient to support the level of service.
Review of Systems (ROS)
The ROS documents an appropriate review of relevant organ systems as determined by the presenting problem(s). While specific element counts are no longer required for code-level selection under the 2025 guideline changes, documentation should still reflect the systems reviewed in the context of the encounter.
Physical Examination (PE)
The physical examination must be medically necessary based on the presenting problem(s). There are no restrictions under the current rules governing the physical exam, which are under the provider’s discretion, with reasonable medical necessity to support the exam-based clinical decisions. The documentation should include the medically necessary findings about the patient’s condition.
Medical Decision-Making (MDM)
The documentation must reflect the three elements of MDM: complexity of problems, data review/analysis, and risk. For CPT 99203, the MDM illustrates a low level of complexity. The medical record must describe the number and type of problems addressed, the tests or records reviewed, and the level of risk for complications or morbidity.
Time Documentation
When employing the time-based methodology, it is expected that the documentation will indicate the total time spent on the date of the encounter. The total amount of time for CPT 99203 is 30–44 minutes. The documented time should reflect both the amount of face-to-face time and the amount of non-face-to-face time that the practitioner personally spent on that date.
Differences Between CPT 99202, CPT 99203, and CPT 99204
| CPT Code | Patient Type | Key Requirements | Time (Total on Date of Encounter) | Level of MDM | Typical Clinical Scenario |
| 99202 | New patient (has not received professional services from the same specialty/group in the past 3 years) | Medically appropriate history and/or examination and straightforward MDM | 15–29 minutes | Straightforward (minimal or no data review, minimal risk) | New patient presenting with a minor, self-limited problem (e.g., uncomplicated upper respiratory infection) |
| 99203 | New patient (same definition) | Medically appropriate history and/or examination and low-complexity MDM or 30–44 minutes total time | 30–44 minutes | Low complexity (two or more minor problems, one stable chronic illness, or one acute uncomplicated illness/injury) | New patient with several minor issues or one stable chronic disease needing minimal intervention |
| 99204 | New patient | Medically appropriate history and/or examination and moderate complexity MDM or 45–59 minutes total time | 45–59 minutes | Moderate complexity (e.g., multiple stable chronic illnesses, new problem with uncertain prognosis, acute illness with systemic symptoms) | New patient with complex presentation: e.g., multiple comorbidities, diagnostic uncertainty, or moderate risk of complications |
CPT 99203 Reimbursement Rates & Medicare Rules
Under the 2025 Medicare Physician Fee Schedule (PFS) final rule, CMS provides the base payment amounts for office/outpatient E/M services (for example, codes 99202-99205).
While CMS makes the national conversion factor and RVUs available, reimbursement for services rendered in your town can vary according to geographic payment adjustments (GPCIs) or based on payment stipulations in contracts with various payers.
It is critical to document a level that matches the level selected; if documentation does not support the level selected, claims for visits may be denied, recouped, or an audit may occur. In addition, if the E/M service is provided on the same day as a preventive visit or vaccination, the provider must check for add-on or modifier TC requirements, including G2211 for complexity add‐on under specific regulations (effective 2025).
Conclusion
Accurate use of CPT 99203 ensures that new patient office or outpatient visits involve low-complexity medical decision-making (MDM). In addition, the time limit is 30–44 minutes of total time that can be coded and billed in full compliance with AMA CPT® 2026 and CMS 2025 E/M guidelines. Proper documentation of the chief complaint, history, review of systems, physical examination, MDM, and any modifier 25 application remains essential for audit readiness and payment accuracy.
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