New patient office or outpatient visit requiring a medically appropriate history and/or examination with low-complexity medical decision-making, or 30–44 minutes of total provider time on the date of the encounter.

Verified May 8, 2026 · 5 sources ↓

Medicare: $117.57
Total RVUs: 3.52
Global, days
Region: General

Drawn from AMACMSAAHKSMedsolercm

Documentation requirements

What must appear in the operative or office note to support the claim.

Source · Editorial brief grounded in 5 cited references ↓

State explicitly whether code selection is based on MDM or total time — do not leave the anchor ambiguous
If billing by time, document total minutes spent on the date of encounter and describe the activities performed (exam, record review, care plan, counseling)
If billing by MDM, document the number and nature of problems, data reviewed, and risk level sufficient to support low-complexity MDM
Confirm new patient status — no face-to-face service with the physician or a physician of the same specialty/group within the past 3 years
Document a medically appropriate history and/or physical examination relevant to the presenting problem
If appending modifier 25 for a same-day procedure, document that the E&M was a separately identifiable service with its own medical necessity

Applicable modifiers

Modifiers commonly billed with this code.

Source · AMA CPT modifier descriptors · CMS NCCI Policy Manual

25 Significant separate E/M 52 Reduced services 57 Decision for surgery 76 Repeat, same physician 77 Repeat, another physician 79 Unrelated during global

What this code covers

Source · Editorial summary grounded in 5 cited references ↓

99203 is the level-3 new patient office visit code. It fits encounters where MDM is low — one self-limited or minor problem, one stable chronic illness, or an acute uncomplicated injury — or where total time on the date of the encounter runs 30–44 minutes. You pick one anchor: MDM or time. If you use MDM, time documentation is irrelevant. If you use time, document total minutes and what filled them (exam, record review, care coordination, counseling).

In orthopedics, 99203 is the workhorse for initial evaluations of new patients presenting with a single, straightforward complaint — a sprain, a stable osteoarthritis presentation, a minor fracture requiring limited workup. It sits between 99202 (straightforward MDM, 15–29 min) and 99204 (moderate MDM, 45–59 min). Upcoding to 99204 without documented moderate MDM — multiple chronic conditions, prescription drug management, independent interpretation of a test — is an audit magnet.

For Medicare patients, G2211 can stack on top of 99203 when the visit represents ongoing management of a single serious or complex condition. The 2026 rule: G2211 is incompatible with modifier 25 on the same claim. If you append modifier 25 to 99203 because a same-day procedure is also billed, G2211 will not pay. Global period is XXX, meaning no global surgical package applies to this E&M code itself.

RVU & reimbursement

Component RVUs and Medicare national rate. Actual payment varies by GPCI locality.

Source · CMS Physician Fee Schedule, RVU26A · January 2026

Work RVU	1.6
Practice expense RVU	1.76
Malpractice RVU	0.16
Total RVU	3.52
Medicare national rate	$117.57
Global period	days

Payment by site of service

Medicare pays different rates by setting. HOPD typically pays substantially more than ASC for the same procedure.

Source · CMS OPPS Addendum B·ASC HCPCS payment rates·2026

Setting	Medicare rate (national)
Office (PFS non-facility) Procedure performed in physician's office	$117.57

Common denial reasons

The recurring reasons claims for CPT 99203 get rejected.

Source · Editorial brief grounded in CMS NCCI edits, AAOS coding appeals, and cited references ↓

Established patient billed as new — prior visit within 3 years by same physician or same-specialty group member
MDM complexity doesn't support 99203 — documented problem is too straightforward or note lacks data and risk elements
Time-based billing without documented total minutes or description of time spent
Upcoding to 99204 or 99205 challenged on audit, leading to retroactive downcoding of the encounter
G2211 denied when modifier 25 is also present on the same claim (2026 CMS rule)
Missing or vague diagnosis linkage — no ICD-10 code that supports medical necessity for the visit level billed

Frequently asked questions

Source · Generated from the editorial pipeline, verified against 5 cited references ↓

01Can I bill 99203 for a patient I saw three years ago at a different practice?

Yes. New patient status applies when the patient has not received a face-to-face service from you or any physician of the same specialty in the same group practice within the past 3 years. A prior visit at a different, unaffiliated practice does not reset that clock.

02Can 99203 and a procedure code be billed on the same day?

Yes, with modifier 25 on the 99203. The note must document that the E&M was a separately identifiable service — not just the pre-work for the procedure. Be aware that appending modifier 25 blocks G2211 from paying on the same claim under 2026 CMS rules.

03What distinguishes 99203 from 99204?

MDM complexity. 99203 requires low MDM (or 30–44 minutes of time). 99204 requires moderate MDM — which typically means managing a prescription drug, ordering an independent interpretation of a test, or dealing with a new or worsening chronic condition. If your orthopedic new patient visit involves managing existing medications or interpreting imaging you ordered, 99204 may be supportable.

04Do I have to document both history/exam AND MDM to bill 99203?

No. Since the 2021 E&M revisions, you only need a medically appropriate history and/or examination — there's no minimum bullet count. MDM alone, or total time alone, drives level selection. Document whichever anchor you're using.

05Can I bill G2211 with 99203 for an orthopedic new patient?

Yes, if the visit represents ongoing management of a single serious or complex condition — for example, managing a patient's hip osteoarthritis over time. G2211 is not appropriate for a one-time consultation or when modifier 25 is also on the claim. Per the AAHKS G2211 Primer, orthopedic surgeons can qualify but should review payer-specific guidance.

06What happens if I document 28 minutes of total time — does that drop to 99202?

If you're billing by time, yes — 28 minutes falls in the 99202 range (15–29 minutes). Switch your anchor to MDM if the encounter supports low complexity regardless of time, which would still support 99203.

Sources & references

Editorial content was developed using the following public sources. Last verified May 8, 2026.

Mira AI Scribe

Mira's AI scribe captures the presenting complaint, problem count and acuity, history elements reviewed, examination performed, data sources consulted (outside records, test results, orders placed), and the clinician's assessment and plan — the exact inputs that determine MDM level. It also timestamps total encounter time when the provider dictates time-based selection. This prevents the most common 99203 audit flag: a note that describes a low-complexity visit but bills 99204 because no one documented MDM components explicitly.

See how Mira captures CPT 99203 documentation