CPT code 99203 is an office or outpatient visit for a new patient that involves a low level of medical decision making (MDM), or enough of the practitioner's total time on the date of the visit to meet the time CPT sets for 99203. It is the second of four new patient levels, 99202 to 99205. Before choosing any of them, confirm the patient really is new: for Medicare, that means no professional service from the practitioner, or from a physician of the same specialty in the same group, in the previous three years.
The level rules come from the AMA's CPT office visit guidelines, in effect since January 1, 2021, and Medicare applies them. Commercial payers and Medicaid plans generally follow CPT too, but some add their own new-patient or documentation policies, so check the payer's policy for the date of service. Payment varies by payer and locality; for Medicare, use the Physician Fee Schedule look-up.
Who counts as a new patient?
Medicare's Claims Processing Manual defines a new patient as one who hasn't received any professional service from the physician, or the physician group practice in the same physician specialty, within the previous three years. A professional service here means an E/M service or another face-to-face service, such as a surgical procedure. CMS's E/M booklet includes nonphysician practitioners in the same definition.
Some details matter in practice:
- Interpretations don't count. If the group only billed the professional component of a test in the last three years, such as reading an x-ray or an electrocardiogram, without seeing the patient face to face, the patient is still new.
- Specialty matters. A patient seen by a cardiologist in the group can be new to the group's dermatologist. CPT's definition says "exact same specialty and subspecialty" and treats advanced practice nurses and physician assistants working with physicians as being in the same specialty as the physician.
- Covering for a colleague. CPT classifies the patient as the absent practitioner would have.
- Three years means three years. Check the date of the last face-to-face service from anyone in the same specialty in the group, including a different location, before scheduling or coding the visit as new.
Patient status is easiest to get right before the visit, when the scheduler can see prior services in the practice management system.
What does 99203 require?
Since 2021, the visit level is chosen by MDM or by total time, not by the amount of history and examination. The history and exam still have to be medically appropriate and documented, but CMS says they no longer affect the level.
By MDM. 99203 requires low MDM. CPT measures MDM with three elements: the problems addressed, the data reviewed and analyzed, and the risk of the management decisions. Two of the three must reach the low level. In the AMA's table, examples of low-level problems include one stable chronic illness or one acute, uncomplicated illness or injury.
By time. The practitioner's total time on the date of the visit counts, face-to-face and non-face-to-face, including preparing, examining, counseling, ordering, documenting and coordinating care. Clinical staff time and separately billed services don't count. The minimum time for 99203 is set in the CPT code descriptor; use the CPT code set in effect on the date of service. For Medicare, the full time must be met and documented, as start and stop times or as the total.
How does 99203 compare with the other new patient codes?
| Code | Level of MDM |
|---|---|
| 99202 | Straightforward |
| 99203 | Low |
| 99204 | Moderate |
| 99205 | High |
Code 99201 was deleted in 2021; claims for it will reject. The established patient codes (99211 to 99215) follow the same structure, and 99214 sits at the moderate level; see the 99214 guide.
Older articles describe 99203 as requiring a "detailed history and examination". That was the pre-2021 rule. Coding from it can push visits up or down a level. A new patient visit is not automatically more complex: code the MDM or time the record shows, and don't choose 99204 just because the patient is new.
What should the note show?
- The patient's reason for the visit and a medically appropriate history and exam.
- The problems addressed and their status, the data reviewed or ordered, and the management decisions made.
- If time is used, the total time on the date of the visit, or start and stop times, spent by the billing practitioner.
- Diagnosis codes that match the problems addressed. CPT vs ICD-10 codes explains how the two code sets meet on a claim.
Can 99203 be billed with a procedure?
Yes, when the visit is significant and separately identifiable from the procedure, and the record shows it. It is then reported with modifier 25. For a minor procedure, the decision to perform it is part of the procedure, not a separate visit. For a major procedure (a 90-day global period), the visit where the surgeon decided to operate is reported with modifier 57. The CO-97 guide explains how same-day visits are bundled.
Medicare's G2211 add-on can be reported with new patient visits too, when the practitioner will be the patient's continuing focal point of care or will provide ongoing care for a serious or complex condition. It doesn't change which level is chosen.
Why do 99203 claims get denied?
- The patient wasn't new under the three-year rule.
- The documentation doesn't support the level, or supports a different one.
- The visit was billed with a same-day procedure without support for a separately identifiable service.
- The diagnosis codes don't support the medical necessity of the visit.
Each is fixed where it starts: patient status at scheduling, level selection at coding, and a documentation review before claims go out. Highview bills new and established patient visits through its physician billing service.
Sources
- CMS, Medicare Claims Processing Manual, Chapter 12, sections 30.6.1 (selection of level of E/M service), 30.6.6 (modifiers 25 and 57) and 30.6.7.A (definition of new patient).
- CMS, Evaluation and Management Services Guide, MLN006764 (May 2026): new and established patients, level selection, time documentation, G2211.
- CMS, Global Surgery booklet, MLN907166 (December 2025): modifiers 25 and 57.
- AMA, CPT E/M office or other outpatient services code and guideline changes (effective January 1, 2021): deletion of 99201, MDM levels for 99202 to 99205, the MDM table, new and established patients, total time.
- CMS, PFS Relative Value Files, RVU26D: 99202 to 99205 active in 2026; 99201 not listed.
- CMS, Search the Physician Fee Schedule.