CPT 99203 is one of the most commonly used Evaluation and Management (E/M) codes for new patient office visits in family medicine. Understanding how to correctly use and document this code is essential for accurate billing, optimized reimbursement, and compliance with CMS and AMA guidelines.
This guide breaks down everything you need to know about CPT 99203—from coding criteria to documentation tips—to help ensure your practice is billing correctly under the 2021+ E/M guidelines.
Key Facts: CPT 99203 (Moderate Complexity)
Time-Based Billing: 2021+ E/M Guidelines for New Patients
In 2021, the CMS and AMA overhauled outpatient E/M coding, allowing providers to bill based on total time or MDM—whichever is more favorable. Here's how CPT 99203 fits into the time-based structure:
Activities That Count Toward Total Time:
- Reviewing external records/labs before the visit
- Pre-visit prep (chart review, history)
- Performing exam & gathering history
- Counseling and educating the patient/caregiver
- Ordering tests/procedures
- Coordinating care or consulting with other professionals
- Documenting in the EHR
- Communicating results or plans after the visit
Always document the total time and a brief summary of activities (e.g., “24 minutes: reviewed prior labs, conducted physical exam, documented visit, and discussed care plan”).
Documentation Checklist for CPT 99203
Even with the simplified 2021 rules, documentation must still support the level of service, either via MDM or time.
1. History (Subjective)
Must be medically appropriate for the visit.
Include:
- Chief Complaint: Reason for the visit
- HPI: Onset, duration, severity, modifying factors
- Relevant Past Medical, Family, Social History as needed
No need for extensive ROS or bullet-point systems—focus on what’s clinically relevant.
2. Examination (Objective)
Also must be medically appropriate.
Include:
- Vital signs (if relevant)
- Focused physical exam findings
- Systems examined based on presenting problem
You no longer need a minimum number of body systems—document only what you examined.
Medical Decision Making (MDM) Criteria for 99203
To qualify under moderate complexity, CPT 99203 requires meeting 2 of the following 3 elements:
A. Number & Complexity of Problems Addressed
- 2 or more stable chronic illnesses
- 1 chronic illness with exacerbation or progression
- 1 acute illness with systemic symptoms (e.g., fever, fatigue)
- 1 acute complicated injury (e.g., head trauma with confusion)
B. Amount/Complexity of Data Reviewed
Must include at least 2 different categories:
- Reviewing prior records or external notes
- Ordering labs/imaging/tests
- Interpreting tests personally (e.g., ECG, CXR)
- Using an independent historian (parent, guardian)
C. Risk of Complications and/or Morbidity
Examples of moderate risk:
- Starting or adjusting prescription medications
- Deciding on minor procedures with risk factors
- Addressing serious social determinants (e.g., food insecurity)
- Managing complex conditions that require close follow-up
99203 vs. 99202: What’s the Difference?
Category
99202 (Low Complexity)
99203 (Moderate Complexity)
MDM Level
Low
Moderate
Time Range
15–19 minutes
20–29 minutes
Typical Problems
- 1 stable chronic condition
- Mild acute illness (e.g., cold)
- 2+ chronic stable conditions
- Worsening chronic issue
- Acute illness with systemic symptoms
Data Reviewed
1 category
2+ categories or independent historian
Risk Level
Minimal (e.g., OTC meds)
Moderate (e.g., Rx drugs, surgery decisions)
Example Scenario
Follow-up for controlled hypertension
New diagnosis of diabetes and depression needing meds
Clinical Tips for Accurate CPT 99203 Billing
Use “Time” when MDM is borderline
If you spent ≥20 minutes and your MDM isn't quite moderate, bill based on time (if supported).
Be specific with your documentation
Instead of vague statements like “reviewed records,” use specifics like “Reviewed ED discharge summary and CBC results.”
Clarify prescription decisions
If initiating or modifying a prescription, document the rationale, patient education, and follow-up plan.
Address Social Determinants of Health (SDoH)
If relevant, note issues like housing insecurity or language barriers. These support moderate risk and justify 99203.
Don’t default to 99203
Not every new patient qualifies. If the visit is straightforward, 99202 is more appropriate—and safer from audit risk.
CPT 99203 in Family Medicine
CPT 99203 is a powerful code for moderately complex new patient visits, but accuracy is essential. Whether you're billing based on total time or medical decision making, your documentation must clearly reflect the complexity of the visit.
Staying compliant and precise with E/M coding not only helps avoid audits but also ensures that your practice is fairly compensated for the care you provide.