Office o/p new low 30 min
CPT code 99203 is used when a doctor sees a new patient in the office for a straightforward problem that requires low-level medical decision making, typically taking about 30 minutes.
RVU breakdown
Conversion factor: 32.3465 · Source: CMS MPFS RVU25A · Confidence: High
Billing tips
Use time-based billing when it favors higher reimbursement: if total time is 40-54 minutes, bill 99204 instead ($167.09) versus 99203 for 30-39 minutes
Impact: Potential increase of $58.08 per visit when time reaches 40 minutes and documentation supports it
Clearly document medical decision making (MDM) elements: number of diagnoses/problems, data reviewed, and risk level to support low complexity MDM
Impact: Prevents downcoding to 99202 ($79.34), protecting $29.67 per visit
Ensure patient is truly 'new' (no professional service from same physician/group in past 3 years); otherwise use established codes 99211-99215
Impact: Billing 99203 for established patient will result in denial or downcoding to 99213 ($93.49), losing $15.52
When billing same day as a procedure, append modifier 25 to 99203 and ensure documentation shows separately identifiable E&M beyond procedural work
Impact: Protects full $109.01 payment that would otherwise be bundled and denied
For telehealth visits, verify payer policies and append modifier 95; ensure proper technology use and documentation meets payer requirements
Impact: Maintains non-facility rate of $109.01; incorrect telehealth billing may result in reduced facility rate ($79.25) or denial
Audit charts quarterly to verify 99203 selection using MDM grid or time; common error is undercoding (99202) or overcoding (99204)
Impact: Undercoding loses average $29.67 per visit; overcoding risks audit and recoupment of $58.08 plus penalties
Common denials
Patient not considered 'new' - received professional service from same specialty within past 36 months
How to appeal: Submit medical records proving no face-to-face professional service in past 3 years, or accept recoding to established patient code 99213 and resubmit with corrected code
Insufficient documentation to support low-level MDM or 30 minutes total time
How to appeal: Provide complete medical record showing two of three MDM elements (problems, data, risk) at low level, OR time log documenting 30-44 minutes with start/stop times and activities performed
Bundled with procedure performed same day - modifier 25 missing or documentation doesn't show separate identifiable service
How to appeal: Resubmit with modifier 25 appended to 99203; include documentation highlighting separately documented history, exam, and MDM beyond what's inherent in the procedure
Duplicate billing - another provider from same group/specialty billed E&M for same patient on same date
How to appeal: Verify with practice whether visits were truly separate and distinct services by different providers; if legitimate, submit records for both encounters showing separate medical necessity; otherwise, withdraw duplicate claim
Frequently asked questions
What is the Medicare reimbursement rate for CPT code 99203 in 2025?
Medicare pays $109.01 for 99203 in non-facility settings and $79.25 in facility settings based on the 2025 Physician Fee Schedule with a conversion factor of 32.3465. The total RVU is 3.37 (1.6 work RVU + 1.61 non-facility PE RVU + 0.16 MP RVU).
How long does a 99203 visit need to be?
For time-based billing, 99203 requires 30-44 minutes of total time spent on the date of encounter. Alternatively, you can bill 99203 based on low-level medical decision making regardless of time. Under 30 minutes with time-based billing would be 99202; 45 minutes or more would support 99204.
What is the difference between 99203 and 99213?
99203 is for new patients (no professional service from same provider/group in past 3 years) while 99213 is for established patients. Both represent similar complexity levels, but 99203 pays $109.01 versus 99213 at $93.49 for Medicare non-facility. Using the wrong patient status will result in claim denial or recoding.
Can I bill 99203 with modifier 25 on the same day as a procedure?
Yes, append modifier 25 to 99203 when a separately identifiable evaluation and management service is performed on the same day as a minor procedure. Documentation must clearly show the E&M service was above and beyond the usual pre/post-procedure work, with separate history, exam, and medical decision making.
What does low level medical decision making mean for 99203?
Low-level MDM requires meeting 2 of 3 elements: limited number/complexity of problems addressed (example: 2 or more self-limited/minor problems), limited data reviewed/analyzed, or low risk of complications. This is defined in the AMA's CPT 2021 E&M MDM table and applies across all new patient codes.
How many RVUs is CPT code 99203 worth?
99203 has a total of 3.37 RVUs in 2025, broken down as 1.6 work RVUs, 1.61 non-facility practice expense RVUs (0.69 facility PE RVUs), and 0.16 malpractice RVUs. This represents moderate physician work and resource intensity for a new patient low-complexity visit.
What are common reasons for 99203 claim denials?
The most common denials are: patient not meeting new patient definition (seen within past 3 years), insufficient documentation to support low-level MDM or 30 minutes, missing modifier 25 when billed with procedures, and duplicate billing when multiple providers see the same patient on the same day.