In today’s evolving healthcare field, understanding the 99203 CPT code is crucial for both medical billing professionals and providers. Whether you’re a physician, billing specialist, or clinic manager, getting this code right can mean the difference between timely reimbursement and frustrating claim denials.
This blog post provides a firsthand, humanized walkthrough of how procedure code 99203 works, what it covers, how it’s reimbursed, and how it compares to similar codes, such as 99202, 99204, and 99205.
99203 is billed when a new patient visit involves a detailed evaluation that requires the provider to make low to moderately complex medical decisions. According to the 99203 CPT code description (2025 update), it includes:
This code falls under evaluation and management (E/M) services for new patients and is widely used in primary care and specialty settings.
At our medical billing company, we’ve seen firsthand how misuse of the 99203 CPT code, such as applying it without supporting documentation, can lead to denied claims or audits. Providers often under-code to avoid scrutiny, but this can result in lost revenue. Others over-code, which increases the risk of compliance issues.
Real insight: Always document time and MDM level accurately. For one of our clients in internal medicine, switching from 99202 to 99203 with proper charting increased monthly reimbursements by 15%.
When a separately identifiable E/M service is performed on the same day as a procedure, Modifier 25 should be attached to 99203.
Example: If a skin lesion is removed and a new patient evaluation is conducted, use:
99203-25
Other relevant modifiers:
Adding the right modifier improves claim acceptance and prevents bundling errors.
There is no specific age limit for 99203. It applies to new patients of any age, as long as the complexity and time requirements are met.
In urgent care, providers often use 99203 when the visit involves more than basic services (e.g., diagnosis of new problems requiring moderate decision-making). Make sure documentation justifies the code, especially for insurance audits.
Code | MDM Level | Time Spent | Reimbursement |
99203 | Low to Moderate | 30–44 mins | ~$110 |
99204 | Moderate | 45–59 mins | ~$170 |
Use 99204 only if your documentation supports moderate complexity AND extended time. Otherwise, 99203 is more appropriate.
Code | MDM Level | Time Spent | Reimbursement |
99203 | Low to Moderate | 30–44 mins | ~$110 |
99204 | Moderate | 45–59 mins | ~$170 |
Use 99204 only if your documentation supports moderate complexity AND extended time. Otherwise, 99203 is more appropriate.
Knowing when to use each helps optimize revenue and compliance.
The 99203 CPT codes may seem straightforward, but there’s real nuance in using them correctly. At our medical billing services company, we’ve helped providers recover thousands in missed revenue by fine-tuning E/M coding and documentation practices.
Understanding the difference between 99202 vs 99203 or how modifier 25 impacts reimbursement isn’t just about compliance—it’s about keeping your practice financially healthy.
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99203 is billed when a new patient visit involves some medical complexity and generally lasts between 30 and 44 minutes. It’s commonly used in internal medicine, family practice, and specialty clinics when a more in-depth evaluation is needed for a new patient.
The main difference between these codes comes down to time spent and the complexity of care involved:
Medicare reimburses approximately $108–$112 for 99203. Private insurance may offer a higher rate depending on contracts. The actual price of 99203 can vary by region and facility, ranging from $120 to $170 for uninsured patients.
Use Modifier 25 when a separately identifiable E/M service is performed on the same day as another procedure. For example, if you treat a new patient and also perform a minor in-office procedure, add -25 to the 99203 code to prevent bundling and ensure correct reimbursement.
Yes, 99203 can be used in urgent care, especially for new patients whose visit involves detailed evaluation or decision-making. However, documentation must clearly support the time spent and medical complexity to justify the code and avoid downcoding.
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