Office or other outpatient visit, new patient, level 3
Audit Defense & Denial Intelligence
Research-based denial patterns from OrbDoc Bill Analyzer
1. Upcoding from 99202 - insufficient low complexity documentation
Common99203 is listed in the top 10 codes used in error. Requires low complexity MDM or 30-44 minutes, but often billed for straightforward visits that should be 99202.
Common Causes
- • Routine new patient intake billed as low complexity
- • Documentation doesn't support low complexity MDM elements
- • Time documented is under 30 minutes
Resolution Strategy
If documentation supports low complexity (multiple problems, limited data review, or low risk), appeal with specific MDM elements. Otherwise accept downgrade to 99202.
💬 Plain Language Explanation
What this means
This is a new patient office visit with a moderate level of complexity. Your doctor performed a detailed examination and made moderate-complexity medical decisions.
Why you might see this
This code is used when you're seeing a doctor for the first time (or haven't seen them in 3+ years) and your visit required a moderate level of evaluation and decision-making.
Common context
Used for new patients with moderate complexity medical issues.
What to ask your provider
"'As a new patient, what made this visit moderate complexity rather than straightforward?'"
Relative Value Units (RVUs)
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Clinical Information
When to Use
New patient visit with low complexity medical decision-making or 30-44 minutes total time
Common Scenarios
Documentation Requirements
- Detailed history including ROS
- Detailed examination (2-7 organ systems)
- Low complexity medical decision-making
- OR document 30-44 minutes total time with activities
Coding Guidelines
Common Modifiers
Bundling Rules
- Subject to three-year new patient definition
Exclusions
- Do not use for established patients (use 99213)
- Do not use if time <30 minutes (use 99202)
- Do not use if time ≥45 minutes (use 99204)
Coding Notes
Clinical scenarios
- Detailed history including ROS
- Detailed examination (2-7 organ systems)
- Low complexity medical decision-making
- Detailed history including ROS
- Detailed examination (2-7 organ systems)
- Low complexity medical decision-making
- Detailed history including ROS
- Detailed examination (2-7 organ systems)
- Low complexity medical decision-making
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Code Details
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PFSRVU Breakdown
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Frequently Asked Questions
CPT 99203 is the billing code for "Office or other outpatient visit, new patient, level 3". New patient visit with low complexity medical decision-making or 30-44 minutes total time
Medicare pays approximately $109.01 for CPT 99203 (national average). Actual payment varies by geographic location due to GPCI adjustments. Hospital and commercial insurance rates are typically 2-4x higher than Medicare rates.
CPT 99203 has a total RVU of 3.18, broken down as: Work RVU 1.60, Practice Expense RVU 1.45, and Malpractice RVU 0.13. RVUs (Relative Value Units) determine Medicare reimbursement rates.
The most common denial reason for CPT 99203 is "Upcoding from 99202 - insufficient low complexity documentation". 99203 is listed in the top 10 codes used in error. Requires low complexity MDM or 30-44 minutes, but often billed for straightforward visits that should be 99202. Common causes include: Routine new patient intake billed as low complexity; Documentation doesn't support low complexity MDM elements. Appeal success rate is approximately 40-60%.
Key documentation requirements for CPT 99203 include: Detailed history including ROS; Detailed examination (2-7 organ systems); Low complexity medical decision-making; OR document 30-44 minutes total time with activities. Missing or incomplete documentation is a leading cause of claim denials for this code.
Bundling considerations for CPT 99203: Subject to three-year new patient definition. Use an NCCI bundling checker to verify specific code combinations before billing.
Common modifiers for CPT 99203 include: 25 (When E/M separate from same-day procedure). Modifiers indicate special circumstances and can affect reimbursement or prevent claim denials.
The typical time requirement for CPT 99203 is 30-44 minutes total time on date of service. Time-based codes require documentation of the actual time spent providing the service.