What is CPT Code 99203

In this article, you will learn about CPT code 99203, its key components, documentation requirements for this code, where to use it appropriately, how to bill 99203 correctly, examples of 99203, and frequently asked questions about 99203.

What is CPT code 99203

CPT code 99203 is one of the codes used in documenting the evaluation and management of new patient visits in a healthcare setup. In medical billing and coding, CPT 99203 is for a new patient evaluation, and it represents the specific services provided by physicians and other healthcare professionals, such as nurses and physician assistants, while managing the patients visiting the healthcare setup for the first time.

Description of CPT code 99203:

” Office or other outpatient visits for evaluating and managing a new patient require a medically appropriate history and examination and low level of medical decision-making. When using time for code selection, 30- 44 minutes of total time spent on the encounter date.”

What are the main components of CPT 99203

CPT 99203 code deals with an office or other outpatient visit to evaluate and manage a new patient. The total time spent on the encounter date under this code is 30-44 minutes. The patient will require a medically appropriate history and examination and a low level of medical decision-making.

The main components of CPT coding that determine the appropriate level of service for this code are as follows:

1. History

History taking includes a detailed history, which requires:

  • A chief complaint
  • An extended history of present illness( HPI)

The history of the present disease contains information about the patient’s current condition, including the onset, duration, severity (moderate under code 99203), location, modifying factors, timing, and associated symptoms. While documenting this code, one should document at least four elements from the abovementioned list. Document all this information and the patient’s chief complaint for the evaluation’s sake.

  • An extended review of systems (ROS)

It includes gathering information about the patient’s symptoms and overall health status by reviewing various body systems and assisting in identifying any relevant medical issues required for the evaluation or treatment. Review of systems (ROS) includes reviewing 2-9 systems of the body.

  • Past family and social history (PFSH)

It contains information about the patient’s medical history, including previous illnesses, surgeries, and medications. The patient’s family history includes hereditary diseases or conditions that may impact the patient’s health. Social history documents the patient’s lifestyle, occupation, and environmental factors. This code documentation covers at least 1 area.

2. Physical Examination:

This component includes a detailed physical evaluation of the patient under the evaluation and management guidelines. It consists of the evaluation of general appearance, the vital signs, auscultation of the lung and heart, external inspection of ears and nose, inspection of conjunctivae and lids, otoscopic examination of external auditory canals, assessment of hearing, an inspection of the nasal mucosa and septum, examination of the oropharynx, palpation of lymph nodes, and evaluation of lower extremities to rule out any edema or inflammation The detailed review identifies any signs of illness, abnormalities, or potential areas of concern.

3. Medical Decision-Making:

The visit coded under 99203 involves a low level of medical decision-making. The number of diagnosis and management options is limited. The amount and complexity of data are also limited, and the risk of complications, morbidity, and mortality is low according to the 99203 CPT code.

Requirements for documenting CPT 99203 code:

Following are some of the requirements while documenting CPT 99203; these requirements document the components of 99203 CPT code:

1. A detailed description of the patient’s chief complaint: The report should include the symptoms of the illness and their impact on the activities of daily living of the patient.

2. Medical notes contain the detailed history of the present illness, including the elements of HPI.

3. A complete physical examination document containing the patient’s 2- 9 body systems review.

4. Medical notes that contain the patient’s medical, family, and social history relating to the presenting complaint.

5. Medical notes about the medical decision-making of low-level E&M, including assessment, diagnosis, and treatment plan, according to the information obtained during the visit.

Where to use the CPT 99203 code

CPT 99203 applies when a patient presents with a health condition with moderate complexity requiring a detailed evaluation and management and low-level medical decision-making. The following are some of the common examples of applying CPT 99203:

1. When a new patient visits with chronic health conditions such as hypertension, asthma, and diabetes, which require a detailed assessment and management.

2. Initial visits of a new patient for acute illnesses or conditions that are not life-threatening but require a detailed evaluation and management, such as minor trauma or respiratory infection.

3. Evaluating complex medical conditions that involve examination of multiple body systems or require coordination with other healthcare professionals, such as a referral to a specialist or dealing with complex comorbidities.

4. Initial visits of the patients referred by other healthcare providers for specialized care or a second opinion. These visits also require a detailed evaluation of the patient’s condition.

5. Initial visits for the patients seeking psychotherapy or psychological assessment. It includes a detailed psychiatric history, symptoms, and risk factors.

How to bill the CPT 99203 code

According to the American Medical Association (AMA) guidelines, proper documentation and coding are required to bill 99203 accurately. The following are some steps to bill CPT 99203:

1. Ensuring a medical necessity: Verify that the patient presents with a moderately complex condition and has not received face-to-face professional services from the same specialty within the same group practice in the previous three years.

2. Thorough documentation of the visit: As mentioned above, a detailed document of all the critical components of 99203 makes it easy to bill 99203 for reimbursement purposes.

3. Accurate coding: It is crucial to ensure accurate coding and use appropriate modifiers (if required) based on payer guidelines. Verify these codes according to the specific coding and billing rules set by Medicare or other third-party payers to avoid claim denials or delays.

4. Verification of reimbursement: The reimbursement of this code varies according to the payer’s geographic location and individual fee schedules. Consider all these factors while billing 99203 to ensure proper reimbursement for services.

When to use modifier 25 with 99203

Modifier 25 is appended with 99203 if the same physician provides any significant, separately identifiable evaluation and management (E&M) service on the same day of the encounter. For example, if the physician is spending almost 40 minutes with a new patient where they also perform an ultrasound, they cannot count the time spent for the ultrasound towards 99203, and it requires separate billing.

Examples of 99203 CPT code:

Following are some of the examples that will further elaborate on when to code 99203:

1. Initial office visit for a 40-year-old male with pain in the posterior aspect of the shoulder.

2. Initial office visit of a 14 years old male with a three-year history of acne on the face, chest, and back.

3. Initial office visit of a 63 years old male with nasal stuffiness and sinus congestion.

Summary of 99203:

History: Detailed

Chief complaint: 1

History of Present Illness (HPI): At least four elements

Review of Systems (ROS): 2-9 systems

Past Medical, Family, and Social History (PFSH): At least one element

Severity: Moderate

Medical Decision-Making (MDM): Low

Time of encounter: 30-44 minutes

Frequently asked questions about CPT code 99203:

Can we code an established patient under 99203

No, 99203 only codes a new outpatient.

What level of Medical Decision-Making is required for 99203

99203 requires low-level medical decision-making.

Can we append modifier 25 with 99203

Modifier 25 is appended with 99203 if the same physician provides any significant, separately identifiable evaluation and management (E&M) service on the same day of the encounter.

What should be the time of the patient-physician encounter while billing 99203

The time with the physician should be 30-44 minutes for 99203.

See Also

97153 CPT Code

Current Version
June 30, 2023
Written By
Asher Ashfaq, OMPT, PT, CPC, CMP

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