99203 CPT Code: Complete Documentation Requirements & Compliance Guide
For healthcare providers billing Medicare, Medicaid, or commercial insurance, understanding 99203 CPT code requirements is essential for proper reimbursement and compliance. This evaluation and management (E/M) code represents a new patient office visit with moderate complexity—but what exactly does that mean for your documentation?
Incorrect coding of 99203 visits can trigger audits, payment denials, and compliance issues. This comprehensive guide breaks down the 99203 CPT code description, documentation requirements, and best practices to ensure your claims are accurate and defensible.
What Is CPT Code 99203?
CPT code 99203 is used for office or other outpatient visits for the evaluation and management of a new patient that requires:
A medically appropriate history and/or examination
Moderate level of medical decision making (MDM)
OR
30–44 minutes of total time spent on the date of the encounter
Since the 2021 E/M guideline changes, providers can choose to code based on either medical decision making or total time—whichever is more advantageous for the specific encounter.
99203 CPT Code Description: Key Components
New Patient Definition
A patient qualifies as "new" if they:
Have not received any professional services from the physician or another physician of the exact same specialty and subspecialty in the same group practice within the past three years
Are being seen for the first time by the billing provider
Moderate Complexity Medical Decision Making
To meet moderate MDM for 99203, you need 2 of 3 elements:
Number and Complexity of Problems
One or more chronic illnesses with exacerbation, progression, or side effects
Two or more stable chronic illnesses
One undiagnosed new problem with uncertain prognosis
One acute illness with systemic symptoms
Amount and/or Complexity of Data
Review of prior external notes from each unique source
Review of test results from each unique source
Ordering of each unique test
Assessment requiring an independent historian
Risk of Complications and/or Morbidity or Mortality
Prescription drug management
Decision regarding minor surgery with identified patient or procedure risk factors
Decision regarding elective major surgery without identified risk factors
Diagnosis or treatment significantly limited by social determinants of health
Documentation Requirements for 99203
Your documentation must clearly support either the MDM level or time spent. Essential elements include:
Chief Complaint
Clear reason for the visit
Patient's own words when possible
History of Present Illness (HPI)
Detailed narrative of the problem
Include relevant associated signs and symptoms
Document pertinent negatives
Medical Decision Making Documentation
Clear problem list with assessment
Document data reviewed (labs, imaging, prior records)
Treatment plan including medications prescribed
Risk factors considered
Time-Based Documentation (if applicable)
Total time spent on date of encounter
Include both face-to-face and non-face-to-face activities
Document specific activities performed
Common 99203 Coding Mistakes to Avoid
Undercoding stable conditions
Two stable chronic conditions can support moderate MDM
Don’t default to 99202 for "simple" visits
Missing prescription drug management
Document all medications prescribed, adjusted, or continued
This alone can elevate risk to moderate
Incomplete data documentation
List each unique source of records reviewed
Document specific tests ordered
Confusing new vs. established patients
Check the three-year rule carefully
Same specialty in same group = established
99203 vs. Other New Patient E/M Codes
99202 vs. 99203
99202: Straightforward MDM or 15–29 minutes
99203: Moderate MDM or 30–44 minutes
Key difference: Complexity of problems and data reviewed
99203 vs. 99204
99203: Moderate MDM or 30–44 minutes
99204: High MDM or 45–59 minutes
99204 requires more complex problems or extensive data review
Reimbursement Rates for 99203
While rates vary by payer and geographic location, 2024 Medicare national average rates include:
99203: Approximately $133.33
99202: Approximately $93.37
99204: Approximately $198.26
Proper documentation supporting 99203 instead of 99202 can mean a 40%+ increase in reimbursement per visit.
Best Practices for 99203 Compliance
1. Train Providers on MDM Elements
Ensure all providers understand the three MDM components
Create quick reference guides for moderate complexity criteria
2. Implement Documentation Templates
Build templates that prompt for MDM elements
Include checkboxes for data reviewed and risk factors
3. Conduct Regular Audits
Review a sample of 99203 claims monthly
Verify documentation supports the code selected
Provide feedback to providers on findings
4. Use Technology for Compliance Monitoring
Leverage AI-powered tools to flag documentation gaps
Automate checks for MDM element documentation
Catch coding errors before claim submission
How Brellium Helps with 99203 Documentation Compliance
Brellium's AI-powered compliance platform automatically reviews every patient encounter to ensure 99203 documentation meets requirements:
Real-time alerts when documentation doesn’t support the selected E/M level
Automated MDM analysis to verify moderate complexity criteria are met
Pre-billing checks to catch undercoding or overcoding risks
Provider feedback with specific guidance on documentation improvements
By automating the review process, Brellium helps practices maintain compliance, optimize reimbursement, and reduce audit risk for all E/M services.
Learn more: Brellium Clinical Compliance Platform
Frequently Asked Questions About 99203
Can I bill 99203 for a telehealth visit?
Yes, 99203 can be billed for telehealth visits if the documentation supports moderate MDM or 30–44 minutes of time. Check payer-specific telehealth policies.
What if I spend 45 minutes but only have straightforward MDM?
You would bill 99204 based on time (45–59 minutes), even if MDM is straightforward. Always code based on the element that supports the higher level when documented appropriately.
Do I need to document both history and exam for 99203?
No. Since 2021, only a "medically appropriate" history and/or examination is required. The level is determined by MDM or time, not history and exam elements.
External Resources for E/M Coding
AMA E/M Services Guidelines – Official CPT coding guidance
CMS Evaluation and Management Services Guide – Medicare documentation guidelines
AAFP E/M Coding Resources – Family medicine coding guidance
