Can you confidently use the correct E/M code to report your service? Many practices lose revenue because of simple coding mistakes. The primary reason? Evaluation and management services are cognitive, involving intangible processes and different levels of decision-making. Hence, many providers either under or overbill these services.
If you are in the same boat, don’t worry! We will help you understand all E/M codes, one at a time, to get proper payments. Today, our topic of discussion is CPT code 99203, a low-level E/M code covering new patient office visits. Let’s start with a simple description!
CPT Code 99203 – Description
So, what exactly does this code cover? And how is it any different from other E/M codes? CPT code 99203 is one of the evaluation and management codes for new patients. To be more specific, it highlights office or other outpatient visits where a healthcare provider spends at least 30 minutes or more evaluating a patient. In short, this office meeting includes:
- Taking the appropriate history of a patient
- Conducting various examinations
- Making low-level medical decisions
The description is quite simple, but many people get confused with “low-level decision-making.” The real question is, how do you determine the complexity of an office or outpatient visit? The American Medical Association (AMA) has answered this in its E/M service guidelines. They have divided the medical decision-making (MDM) groups based on the following three factors:
- Number and complexity of addressed issues
- Volume and/or complexity of data, such as medical records, tests, or any other information, to be analyzed
- The risk of complications or serious issues (morbidity or mortality) in patient care
So, you can use CPT code 99203 if you address two or more minor problems, review previous notes and test results, or order a new assessment, and there is a low risk of complications in patient care.
Scenarios Where CPT Code 99203 is Applicable
Still confused about the complexity of the decision-making? Here are a few scenarios that can help you with that:
Evaluating & Managing a New Patient with an Acute, Uncomplicated Injury
Suppose a 27-year-old man arrives at an outpatient clinic with a sprain in his right ankle. The healthcare provider takes his history and learns that he acquired this injury by falling from a ladder. He documents the symptoms (pain, swelling, and bruising) and conducts a physical examination, including imaging tests and an assessment of swelling and points of tenderness.
After evaluating the pain intensity and extent of damage, the doctor concludes that it is a simple sprain and recommends the R.I.C.E (Rest, Ice, Compression and Elevation) method. Since he addressed only one acute, uncomplicated injury in 30 minutes and made a low-level medical decision, the billing team used CPT code 99203 to report this service.
Evaluating & Managing a New Patient with Two Minor Problems
Let’s consider another example! Assume a 24-year-old woman arrives at a primary care clinic with a flu and a minor skin rash. The physician evaluates the patient and notes consistent coughing, nasal congestion, itchiness, and fatigue.
He takes a detailed history, including her current condition, duration of symptoms, common triggers, and any prior treatments. He then conducts a detailed examination and diagnoses an allergic reaction due to overexposure to heat. The provider prescribes some medications and advises her to minimize her exposure to heat. He then uses CPT code 99203 to bill for his 34 minutes of service.
Evaluating & Managing a New Patient with Stable Chronic Condition
What if a patient visits a new doctor for preventive care? Suppose a 24-year-old man with mild asthma moves to a new state and visits a pulmonologist to manage his condition. The doctor conducts a detailed checkup, reviewing the patient’s medical records and medications to determine if any adjustments are needed.
The patient reports no recent flare-ups and comments that his symptoms are well-controlled. After a comprehensive physical examination of the nose, throat, and airways, the pulmonologist advises him to continue the previous treatment plan for six months, with one addition—exercising with proper warm-up.
The doctor then uses CPT code 99203 to report this 40-minute office visit involving low-level medical decision-making.
Applicable Modifiers for CPT Code 99203
So, was the office visit distinct or separately identifiable? You can use the following modifier to convey this information:
Modifier 25
This is the most commonly used modifier with E/M services. You may apply modifier 25 to CPT code 99203 if the office visit is unrelated to another procedure, such as a minor surgery or an injection, performed on the same day.
For example, a new patient visits a clinic for a joint injection (CPT code 20610). However, he is also evaluated by the same physician for a separate issue. Hence, the doctor uses Modifier 25 with CPT code 99203 to indicate that the E/M service is distinct and separately billable.
CPT Code 99203 vs. 99202
So, how does CPT code 99203 differ from CPT code 99202? Both codes refer to an E/M office or outpatient visit of a new patient. However, they have different durations and levels of medical decision-making (MDM). Here are a few key differences between CPT codes 99203 and 99202:
Depth of Medical History & Examination
Depth of medical history and examination are a key difference between CPT codes 99202 and 99203. These assessments help healthcare providers determine the level of an office visit.
Since CPT code 99202 refers to a simple office visit, the doctor takes a problem-focused history and examination. This means he only addresses a specific problem and performs a limited review of systems (ROS).
On the other hand, CPT code 99203 covers a more detailed history and examination. In simple terms? The provider evaluates two or more minor problems and conducts a more comprehensive physical assessment.
Level of Medical Decision-Making (MDM)
MDM is another key difference between the two codes. CPT code 99202 includes straightforward medical decision-making. It simply means the provider addresses one minor problem and reviews minimal or no data, such as test results, to develop a treatment plan.
In contrast, CPT code 99203 reports low complexity medical decision-making. This means the patient’s condition is slightly more complicated, requiring the provider to evaluate multiple conditions, review limited data, and manage a stable chronic or acute illness.
Time Length
The length of the office visit also differs between these codes. CPT code 99202 covers a shorter office or outpatient visit, typically lasting 15 to 29 minutes. On the other hand, healthcare providers apply CPT code 99203 to longer, more detailed sessions, ranging from 30 to 44 minutes.
| Key Differences Between CPT Codes 99203 & 99202 | ||
|---|---|---|
| Components | CPT Code99202 | CPT Code 99203 |
| History & Examination | Problem-focused | Detailed |
| MDM | Straightforward | Low-level |
| Average Session | 15 to 29 minutes | 30 to 44 minutes |
| Addressed Issues | Minor issue | Two or more minor problems |
| Patient Management Complexity | Minimal risk | Low risk |
CPT Code 99203 – Billing & Reimbursement Guidelines
E/M coding can be quite intimidating. However, you can overcome anything if you have a strategic plan. Don’t know how to justify the use of CPT code 99203? Follow our billing and reimbursement guidelines mentioned below:
Verify Patient Eligibility
Before coding any E/M service, the first step is to confirm whether the patient is new or established. CPT code 99203 applies to new patients.
So, who qualifies as a new patient? The AMA classifies new patients as individuals who have not received any professional services from a practice within the past three years. This includes services provided by physicians or other qualified healthcare professionals of the same specialty.
Therefore, before using CPT code 99203, verify that neither you nor any other physician or qualified healthcare provider in your group practice has attended to the patient in the last three years.
Document Medical Necessity
You should always back your decision to use the CPT code 99203 with complete documentation, which includes the following five key components:
Medical History
Medical history is further divided into four essential elements:
- Chief Complaint (CC) – The primary reason for the patient’s visit.
- History of Present Illness (HPI) – Details about the patient’s current symptoms.
- Review of Systems (ROS) – Targeted questions to assess the patient’s overall condition.
- Past Medical, Family, and Social History (PFSH) – The patient’s past conditions, family history, and lifestyle habits.
This section is crucial as it helps insurance companies evaluate the medical necessity of an initial office visit.
Physical Examination
You should also record the entire process of diagnosing the patient, including all the tests you conducted to develop a treatment plan. Keep one thing in mind! This section should support the history of the present illness (HPI) and review of systems (ROS).
Medical Decision-Making (MDM) Process
Documenting the MDM process will also help you justify using CPT code 99203. Remember that you can only apply this code to an E/M service if:
- You addressed two or more minor problems/ one stable chronic illness/one stable acute illness/ one acute, uncomplicated illness or injury.
- You reviewed either prior external notes or test results and ordered additional assessments.
- There is a low risk of complications from further assessments or prescribed treatments.
To summarize, document everything—from the evaluated conditions and the reviewed data to the tests conducted and the associated risks.
Note the Duration of the Session
The average length of a session can also help you justify the use of CPT code 99203. Hence, note down the time you spent evaluating and managing a new patient’s condition. This code typically covers a 30-to-44-minute patient encounter.
Highlight the Treatment Plan
Finally, outline the treatment plan to complete your documentation. This includes recording:
- Prescribed medications
- Lifestyle recommendations
- Follow-up care instructions
- Any additional recommendations
Apply the Correct Modifiers (If Required)
If you have provided any additional service to the same patient on the same day, use an appropriate modifier to receive a separate payment.
For example, if the initial patient encounter is separate and uniquely identifiable from another procedure, you can append modifier 25 to CPT code 99203.
Check Payer-Specific Requirements
CPT 99203 is a time-based code representing a different level of complexity in patient evaluation and management. Hence, its reimbursement rate varies from other E/M codes for new patients. Check Medicare and other private insurers’ guidelines to avoid billing issues and payment delays.
Conclusion
CPT code 99203 is a key E/M code for billing and documenting new patient visits. This time-based code involves a detailed history and physical examination of a patient and low-level decision-making.
Since the E/M services are cognitive, healthcare providers working in family medicine, pediatrics, internal medicine, and cardiology rely on these components to choose between different options. However, the reimbursement requirements for CPT code 99203 are quite complex. Therefore, we have covered it in detail so you can file accurate claims and receive timely payments for efficient evaluation and management of new patients. However, if it seems too consuming, you can always outsource pediatric billing services to our certified professional coders at MediBillMD. They are adept at the accurate usage of all E/M service codes, including CPT code 99203.
