Office visit for a new patient
CPT® Code 99203 is used to report an office or other outpatient visit for the evaluation and management (E/M) of a new patient. This code applies when the total time spent on the encounter is between 30 and 44 minutes, or when the medical decision making (MDM) is of low complexity. It is typically used for visits involving patients with less complex medical concerns than those seen under the higher-level new patient codes (99204 and 99205), but still requiring evaluation, diagnosis, and initial treatment planning.
When to use CPT® Code 99203
This code is appropriate when:
- The patient is a new patient to the practice and requires an evaluation and management of a medical condition.
- The conditions addressed are of low complexity, such as a mild acute illness or a stable chronic condition with no significant exacerbation.
- The provider spends 30 to 44 minutes on the date of the encounter conducting necessary evaluations, performing a physical exam, and making treatment decisions.
- The visit requires a low level of medical decision making or moderate data review, and no major risks are involved in diagnosis or treatment.
The service may be reported based on either medical decision making or total time spent on the encounter.
Medical decision making requirements
To use medical decision making (MDM) as the basis for selecting CPT 99203, the visit must involve low complexity MDM. This typically includes:
- Number and complexity of problems addressed: A single acute illness or injury, or a stable chronic illness that does not present a significant risk to the patient.
- Amount and/or complexity of data reviewed and analyzed: Limited data review such as basic lab or diagnostic test results or a minimal number of records to consider.
- Risk of complications and/or morbidity or mortality: Low risk associated with the condition, diagnostics, or treatment decisions.
Time requirements
When coding based on time, all activities performed by the provider on the date of the encounter can be included. For CPT 99203, total time must be between 30 and 44 minutes and includes:
- Reviewing the patient’s medical history and any available test results
- Performing an examination and evaluation
- Counseling and educating the patient or family
- Ordering tests or treatments
- Documenting findings in the medical record
- Referring the patient or coordinating care with other healthcare professionals (if not separately billed)
- Communicating results to the patient or family
Note: Do not include unrelated administrative tasks or activities that don’t directly contribute to the current patient encounter.
Key documentation tips
To accurately support the use of CPT 99203:
- Clearly document the total time spent on the encounter if coding based on time.
- Provide detailed information on the nature of the problem (acute, stable chronic, etc.), risks involved, and treatment decisions made.
- Include relevant history and exam findings, and ensure the documentation supports the level of service provided.
- Specify if coding is based on MDM or time, and make sure the appropriate criteria are met for low complexity.
How OptiMantra supports accurate coding for CPT® 99203
OptiMantra is an ideal tool to help practices efficiently and accurately document visits, including lower-complexity new patient visits like CPT 99203. Here’s how OptiMantra helps:
- Integrated time tracking, automatically logging time spent on each patient encounter, ensuring accurate time-based coding.
- Smart EHR templates that guide providers to capture all essential components for CPT 99203, including history, exam, and MDM.
- Real-time coding suggestions based on entered clinical data, helping providers confidently select the correct CPT code.
- Audit-friendly documentation, with structured and timestamped records that meet compliance and payer requirements.
- Seamless EHR-to-billing integration, reducing billing errors and accelerating reimbursement.
By using OptiMantra, healthcare providers can ensure they are capturing the full value of their services and staying compliant with coding standards, all while minimizing administrative burdens.
