CPT 99203 may be reported for Office or other outpatient visit for the evaluation and management of a new patient (30-44 minutes). Furthermore, the 99203 CPT code is reimbursed when 30-44 minutes is spent during encounter with a patient. The reimbursement rate is between $84.44 and $113.75 and modifier 25 may be applied.
99203 CPT Code Description
99203 CPT code description is defined by the CPT manual as follows (the text in Italic is the official definition of CPT 99203):
‘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 time for code selection, 30-44 minutes of total time spent on the date of the encounter.
99203 CPT Code Reimbursement
Furthermore, providers report this code when new patients are being seen in the Doctor’s office, clinic or other outpatient clinic. This code is billed by using document complexity or by using total time spent. This code should never be used for any inpatient, nursing or home facility as for each time of facility; there is separate category of E&M codes.
For CPT 99203, you need;
- Medical appropriate;
- History and examination and;
- Low level Medical decision-making.
OR 30-44 minutes time is spent during an encounter with the patient. (Not face-to-face time anymore).
Before Oct, 2021 coding updates, you need to calculate the history and examination section using E&M points calculator. Now you only need the history and examination to be mentioned appropriately and MDM section according to previous score calculations.
In addition to this, the Medical History or Examination section of office/outpatient evaluation and management guidelines explains that office and other outpatient E/M services should include ‘a medically appropriate history and an appropriate physical examination when performed.
Now what does ‘medically appropriate’ mean?
’Medically appropriate’ means that the Doctor, Provider or any qualified healthcare professional who is going to report the E/M should determine the nature and extent of any Medical history or physical examination for a particular medical service. Please note that the selection of code does not depend on the level of history or exam.
Following is the score calculation criteria for low level MDM:
- Number and complexity of problems addressed: Low (2 minor or 1 stable chronic or 1 acute illness)
- Amount and complexity of data reviewed: Limited
- Mortality of patient management: Low risk (from additional testing and treatment options selected)
Equally important, anyone can use CMS E&M auditor tool to select an E&M code and can also perform internal audit of practice while educating about importance of documenting medical services in notes.
What Is The Charge For CPT Code 99203?
The charge rate for the 99203 CPT Code is provided by CMS. The insurances who follow Medicare will pay at the same rate.
- Charge Facility: $84.44
- Charge Non-facility* (clinic): $113.75
CPT Code 99203 New Patient
CPT 99203 can be used to code new patients. As per CMS guidelines, a Medical provider and Medical biller should have clear understanding of what is a new patient and what is an established patient. Furthermore, a new patient visit cost more dollar amount to healthcare insurance than established patient does did.
A new patient is a patient who has not received treatment and any kind of professional services from the Doctor or qualified health care professional. This includes, any other physician or qualified health care professional of the exact same specialty and subspecialty from the same group practice, within the last three years.
Example: Today a John Smith has come to office who has not been addressed by Doctor A (Family medicine) in past 3 years. However, he was seen by another Doctor B, who is also a family medicine doctor, last month. In that case the patient will be an established patient and you will code from CPT 99211 – CPT 99215.
However, if the patient was seen by a neurologist, but not by Doctor A or B in last 3 years, provider will code it as 99203 CPT Code depending on the time and Medical notes.
CPT 99203 And Modifier 25
Modifier 25 can be used for 99203 CPT code. Underneath you will find a description of Modifier 25 and how it can be used to report CPT 99203.
What Is Modifier 25?
Definition of modifier 25 is “significant, separately identifiable evaluation and management (E/M) service by the same physician on the same day of the procedure or other service.”
Can Modifier 25 Be Reported With CPT 99203?
Yes. In fact, the description of Modifier 25 states that if there is any service that is provided on the same day encounter by the provider, we may append Modifier 25 with CPT 99203.
How To Code CPT 99203 And Modifier 25
If you have a new patient and the provider is spending almost 40 minutes with them where they’re also performing an ultrasound (CPT 76802), then you should be very careful in selecting CPT code 99203. Ultrasound should be billed separately and time spent for that ultrasound cannot be counted towards CPT 99203. We can use 25 Modifier with 99203 CPT and in this case also CPT 76802.
CPT 99203 And Modifier 25 Example
A patient goes to a Dermatologist for regular check-ups. During these encounters, the dermatologist finds a suspicious lesion at the shoulder. They decide to take a biopsy for further evaluation.
Now they have the 99203 CPT code and there is separate service which is performed and coded with CPT 11104. In this case, CMS requires them to put modifier 25 with CPT 99203 to show that these services were separately identifiable and do not overlap. If they do not append Modifier 25, they will not get reimbursement for the 99203 CPT code and that will be a potential loss to the doctor.
99203 CPT Code Description Time
Let’s say a patient goes to a psychiatrist and the Doctor spends most of their time doing counselling or talking to other providers because of an already known mental condition of the patient. In this case, If we select the code based on MDM, it may not be suitable for work that psychiatrist put in.
Activities That Count Toward Total Time
- Referring a patient
- Getting and observing the history
- Documentation work
- Talking to other provider about patient condition
- Ordering medications
- Reviewing the test results
Remember that clinical staff time or time spent for other separately identifiable service should not be count for CPT 99203. Each code has definitive RVUs value and time attached to it by CMS, If a doctor tries to include the time of other service in 99203 will be designated as fraud.
Difference Between 2020 And 2021 Time Guideline
Until 2020, time was calculated as “The typical time spent face-to-face in the office or other outpatient setting with the patient, and can only to be used as a key component for code selection when counseling and/or coordination of care is more than 50% of the visit”
But now after 1st Oct 2020 “The minimum time represents total time spent by physician/qualified health care professional (QHP) on the date of service”
Time should be mentioned in medical notes to append any code, If there is no time mentioned you will have to code the encounter according to medical document. Using the 99203 CPT code based on time while not being mentioned in medical notes will get a medical practice into audit.
CPT 99203 RVUs
The following table shows the total RVUs for the first quarter of 2021 and the fourth quarter of 2020 for 99203. The RVUs of the MPFS facilities are typically lower than the RVUs of the non-facility (office). This is because the physician is responsible for less practical costs when a physician provides services in a facility. Final reimbursement amounts for E / M services don’t just depend on these RVUs.
- CPT 99203 2020 Q4 RVUs – 3.03 (Non-Facility) – 2.14 (Facility)
- CPT 99203 2021 Q1 RVUs – 3.28 (Non-Facility) – 2.42 (Facility)
One policy change in the 2019 MPFS final rule that received a good response from providers was the plan to pay a one-time fee called a combined fee. Medicare intended to pay the same fee for the new patient CPT codes 99202 – 99204, regardless of which CPT code was reported.
Medicare would pay another one-time fee for established patient CPT codes 99212 – CPT 99214. Level 5 visits CPT 99205 and CPT 99215 would have separate fees to reflect the greater complexity of these codes.
99203 CPT Code Examples
Initial office visit of a 76-years-old male with a stasis ulcer of three months’ duration. (Dermatology)
Initial office visit for a 30-years-old female with pain in the lateral aspect of the forearm. (Physical Medicine & Rehabilitation)
Initial office visit for a 15-years-old patient with a four-year history of moderate comedopapular acne of the face, chest, and back with early scarring, Discussion of use of systemic medication. (Dermatology)
Initial office visit for a patient with papulosquamous eruption of the elbow with pitting of nails and itchy scalp. (Dermatology)
Initial office visit for a 57-years-old female who complains of painful period swelling of one week’s duration. (Oral & Maxillofacial Surgery)
Initial office visit for a patient with an ulcerated non-healing lesion or nodule on the tip of the nose. (Dermatology)
Initial office visit for a patient with dermatitis of the antecubital and popliteal fossae. (Dermatology)
Initial office visit for a 22-years-old female with irregular menses. (Family Medicine)
Initial office visit for a 50-years-old female with dyspepsia and nausea. (Family Medicine)
Initial office visit for a 53-years-old laborer with degenerative joint disease of the knee with no prior treatment (Orthopaedic Surgery)
Initial office visit for a 60-years old male with Dupuytren’s contracture of one hand with multiple digit involvement. (Orthopaedic Surgery)
Initial office visit for a 33-years-old male with painless gross hematuria without cystoscopy. (Internal Medicine)
Initial office visit for a 55-years-old female with chronic blepharitis, There is a history of use of many medicines. (Ophthalmology)
Initial office visit for an 18-years-old female with a two-day history of acute conjunctivitis, Extensive history of possible exposures, prior normal ocular history, and medication use is obtained. (Ophthalmology)
Initial office visit for a 14-years-old male with unilateral anterior knee pain. (Physical Medicine & Rehabilitation)
Initial office visit of an adult who presents with symptoms of an upper-respiratory infection that has progressed to unilateral purulent nasal discharge and discomfort in the right maxillary teeth. (Otolaryngology/head & Neck Surgery)
Initial office visit of a 40-years-old female with symptoms of atopic allergies including eye and sinus congestion, often associated with infections. She would like to be tested for allergies. (Otolaryngology/Head & neck Surgery)
Initial office visit of a 65-years-old with nasal stuffiness. (Otolarygology/Head & Neck Surgery)
Initial office visit for initial evaluation of a 48-years-old man with recurrent low back pain radiating to the leg. (General Surgery)
Initial office visit for evaluation, diagnosis, and management of painless hematuria in a new patient, without cystoscopy. (Internal Medicine)
Initial office visit with couple for counseling concerning voluntary vasectomy for sterility, Spent 30 minutes discussing procedure, risks and benefits, and answering questions. (Urology)
Initial office visit of a 49-years-old male with nasal obstruction, Detailed exam with topical anesthesia. (Plastic Surgery)
Initial office visit for evaluation of a 13-years-old female with progressive scoliosis. (Physical Medicine & Rehabilitation)
Initial office visit for a 21-years-old female desiring counseling and evaluation of initiation of contraception. (Family Practice/Internal Medicine/Obstetrics & Gynecology)
Initial office visit for a 49-years-old male presenting with painless blood per rectum associated with bowel movement. (Colon & Rectal Surgery)
Initial office visit for a 19-years-old football player with three-day-old acute knee injury; now with swelling and pain. (Orthopaedic Surgery)