This 99203 CPT® lecture reviews the procedure code definition, progress note examples, RVU values, national distribution data and explains when this code should be used in the clinic and hospital setting. CPT stands for Current Procedural Terminology. This code is part of a family of medical billing codes described by the numbers 99201-99205. CPT® 99203 represents the mid (level 3) office or other outpatient new patient visit and is part of the Healthcare Common Procedure Coding System (HCPCS). Make sure to also review the lecture on the level 4 new clinic visit as well. A patient is considered outpatient until inpatient admission to a healthcare facility occurs. This procedure code lecture for new office patient visits is part of a complete series of CPT® lectures written by myself, a board certified internal medicine physician with over ten years of clinical hospitalist experience in a large community hospitalist program. I have written my collection of evaluation and management (E/M) lectures over the years to help physicians and non-physician practitioners (nurse practitioners, clinical nurse specialists, certified nurse midwives and physician assistants) understand the complex criteria required to stay compliant with the Centers for Medicare & Medicaid Services (CMS) and other third party insurance companies.
You can find my entire collection of billing and coding CPT® lectures together in one place on my Pinterest site (CPT® lectures here and other associated E/M lectures here). You don't need to be a Pinterest member to get access to any of my CPT® procedure lectures. As you master these E/M procedure codes, remember, you have an obligation to make sure your documentation supports the level of service you are submitting for payment. The volume of your documentation should not be used to determine your level of service. The details of your documentation are what matter most. In addition, the E/M services guide says the care you provide must be "reasonable and necessary" and all entries should be dated and contain a CMS defined legible signature or signature attestation, if necessary.
My interpretations discussed below are based on my review of the 1995 and 1997 E&M guidelines, the CMS E&M guide and the Marshfield Clinic audit point system for medical decision making. These resources can be found in my hospitalist resources section. The Marshfield Clinic point system is voluntary for Medicare carriers but has become the standard audit compliance tool in many parts of the country. You should check with your own Medicare carrier in your state to verify whether or not they use a different criteria standard than that for which I have presented here in my free educational discussion. I recommend all readers obtain their own updated CPT® reference book as the definitive authority on CPT® coding. I have provided access through Amazon to the 2015 CPT® standard edition pictured below and to the right. CPT® 99203 is an office or other outpatient procedure code and can be used by any qualified healthcare practitioner to get paid for their office or other outpatient new patient services. The American Medical Association (AMA) describes the 99203 CPT® procedure code as follows:
You can find my entire collection of billing and coding CPT® lectures together in one place on my Pinterest site (CPT® lectures here and other associated E/M lectures here). You don't need to be a Pinterest member to get access to any of my CPT® procedure lectures. As you master these E/M procedure codes, remember, you have an obligation to make sure your documentation supports the level of service you are submitting for payment. The volume of your documentation should not be used to determine your level of service. The details of your documentation are what matter most. In addition, the E/M services guide says the care you provide must be "reasonable and necessary" and all entries should be dated and contain a CMS defined legible signature or signature attestation, if necessary.
99203 MEDICAL CODE DESCRIPTION
My interpretations discussed below are based on my review of the 1995 and 1997 E&M guidelines, the CMS E&M guide and the Marshfield Clinic audit point system for medical decision making. These resources can be found in my hospitalist resources section. The Marshfield Clinic point system is voluntary for Medicare carriers but has become the standard audit compliance tool in many parts of the country. You should check with your own Medicare carrier in your state to verify whether or not they use a different criteria standard than that for which I have presented here in my free educational discussion. I recommend all readers obtain their own updated CPT® reference book as the definitive authority on CPT® coding. I have provided access through Amazon to the 2015 CPT® standard edition pictured below and to the right. CPT® 99203 is an office or other outpatient procedure code and can be used by any qualified healthcare practitioner to get paid for their office or other outpatient new patient services. The American Medical Association (AMA) describes the 99203 CPT® procedure code as follows:
Office or other outpatient visit for the evaluation and management of a new patient, which requires these three components: A detailed history; A detailed examination; Medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. Physicians typically spend 30 minutes face-to-face with the patient and/or family.
A new patient is defined as a patient who has not received professional services from a doctor or another doctor of the exact same specialty and subspecialty who belonged to the same group practice within the past three years. The definition of a new patient was updated in 2012.
This medical billing code can be used for time based billing when certain requirements are met. However, documentation of time is not required to remain compliant with CMS regulations. If billed without time as a consideration, CPT® 99203 documentation should comply with the rules established by the 1995 or 1997 guidelines referenced above. The three important coding components for an new patient office or other outpatient visit are the:
- History
- Physical Exam
- Medical Decision Making Complexity (MDM)
- Detailed history: Requires four or more elements of the history of present illness (HPI) OR documentation of the status of three chronic medical conditions. One element from the past medical history or social history or family history is also required. The review of systems should inquire about the system directly related to the HPI and at least 2-9 additional systems.
- Detailed examination: 1997 guidelines require documentation of at least 12 elements identified by a bullet in two or more organ systems(s) or body area(s). Alternatively, documentation of six organ systems or body areas with at least 2 bullet elements each is allowed as well. 1995 guidelines require an extended examination of the affected body area(s) and other symptomatic or related organ system(s). The CMS E&M guide on pages 31 and 32 describes the acceptable body areas and organ systems on physical exam.
- Medical decision making of low complexity (MDM): This is split into three components. The two out of three highest levels in MDM are used to determine the overall level of MDM. The level is determined by a complex system of points and risk. What are the three components of MDM and what are the minimum required number of points and risk level as defined by the Marshfield Clinic audit tool?
- Diagnosis (2 points)
- Data (2 points)
- Risk (low); The risk table can be found on page 37.
CLINICAL EXAMPLES OF CPT® 99203
What are some progress note documentation examples for a CPT® 99203, the level 3 new patient visit in an office or other outpatient setting? Many doctors use the subject, objective, assessment and plan (SOAP) note format for their documentation, although this is not a required format. A CPT® 99203 note could look like this:
In this example, the history (subjective), physical (objective) and MDM (assessment and plan) components all meet the minimum requirements to get paid for a 99203 new patient outpatient clinic visit based on the definition of this CPT® code detailed above. Remember, the code group (99201-99205) requires all three elements (history, physical, MDM) to meet the minimum level of service as opposed to the outpatient established code group (99211-99215) which has the two out of three requirement. Stated another way, the lowest level of documentation from history, physical and MDM will determine the overall appropriate level of service for new clinic patient evaluations. If the MDM and physical meet criteria for 99203 but the history only meets the criteria for a 99202 visit, then 99202 is the correct code to choose for the visit. Taken to the extreme, if the MDM and the physical exam both meet criteria for 99205 but the history only meets the criteria for a 99201 evaluation, then the correct code to choose is 99201. Here is another example of an appropriately coded 99203 new patient office visit:Subjective: Abdominal pain. RLQ. Started yesterday. Constant. 2/10. (at least 4 HPI). No nausea, chest pain, dizziness, shortness of breath (at least 2 additional ROS). Nonsmoker (at least one element from past history, social history and family history).Objective: 120/80 80 Tmax 98.9 (three vital signs = one bullet) abdomen no masses, positive bowel tones, RLQ tender with guarding; lungs clear; heart no murmur, RRR; legs no edema; skin no rash, eyes, no icterus, no JVD, alert, mild distress. (at least 12 total bullets in 2 areas)Assessment: 1) Abdominal Pain NOS 2) HTN-controlled (2 points for diagnosis)Plan: Trial of Tylenol for pain (OTC medications are considered low risk for management options on risk table)
History: Cough resolved; No SOB; No CP (2-9 ROS). Stopped taking lisinopril due to cough (one element from past medical history)Physical Exam: 140/80 80 Tmax 98.9 (three vital signs = one bullet) alert, NAD, no icterus, no JVD, abdomen no masses; no palpable organomegally; lungs clear, normal chest wall motion; heart no murmur, regular rhythm; legs no edema, symmetric size; skin no rash or cyanosis, fingernails normal (at least 12 total bullets from two or more areas)Assessment: HTN-worse, see med changes.DM-stable, no changes planned.COPD-stable, no changes planned. (the status of three chronic medical conditions in place of HPI) (3 points for diagnosis under MDM)Plan: Start ARB for HTN. (prescription management is moderate risk on the risk table)
As you know, documenting the status of three chronic medical conditions can substitute for the HPI. Add in at least 2 additional review of systems and one element from past medical family and social history and this is the minimum history documentation required for CPT® 99203. With at least 12 bullets documented in the physical exam and a minimum of low complexity for MDM (this visit actually meets criteria for moderate complexity), this note is complete and accurate and meets documentation requirements to get paid for a new patient level three office visit (99203). All physical exam components offer value to the encounter to exclude potential complications of therapy or to search for evidence of decompensation of disease.
The MDM is of moderate complexity. This MDM documentation gets four diagnosis points for discussing two stable problems (two points total for DM and COPD) with an established problem that's worsening and no more work up planned (two points for HTN). In addition, zero points are earned for the data component, but risk is moderate based on prescription drug management. Prescription drug management is considered moderate risk, as is detailed on my bedside E/M reference card shown below. That means, the highest two out of three components for MDM is moderate. While the MDM is of moderate complexity, the overall correct level of service is limited by history and physical documentation that only supports a level 3 service. And remember, for new patient outpatient visits, the correct code is supported by the lowest level of documentation for history, physical and MDM.Below is another example of a new patient 99203 office visit:
S: HA present 4/10, global pain for 3 days and constant. No ringing in the ears (at least 4 HPI). No nausea/vomiting. No chest pain or SOB. (at least 2 additional ROS) No FH brain cancer. (one element from family history)This new patient outpatient evaluation is appropriate for CPT® 99203 as the history, physical and MDM all contain necessary the necessary documentation based on the Marshfield Clinic audit tool. Medical decision making is moderate because the diagnosis element is high complexity (4 points for new diagnosis with more work-up planned), the data element is low complexity (only one point for ordering lab), and the risk table is moderate for dealing with an undiagnosed new problem with uncertain prognosis. Therefore, the highest two out of three elements in MDM is moderate. Here is another progress note example of a level 3 new patient office visit:
O: 120/80 80 Tmax 98.9 (three vital signs = one bullet) alert, head atraumatic, NAD, no icterus, no JVD, abdomen no masses; no palpable organomegally; lungs clear, normal chest wall motion; heart no murmur, regular rhythm; legs no edema, symmetric size; skin no rash or cyanosis, fingernails normal. (at least 12 total bullets from two or more areas)
A: Acute HA, NOS. Stable. (one new problem with more work up planned and of uncertain prognosis is 4 points on MDM for diagnosis and also moderate risk too)
P: Check CBC/BMP.
S: 48 year old male here to establish care. No CP/SOB/N/V/HA. No polyuria, polydypsia. (at least 2 additional ROS) Nonsmoker. (one element from social history)Both the history and physical meet minimum criteria for CPT® 99203. Medical decision making is moderate based on a moderate risk table assessment and three points in the diagnosis section, which is one point more than is necessary to bill a 99203 new patient office visit.
O: 120/80 80 Tmax 98.9 (three vital signs = one bullet) alert, head atraumatic, NAD, no icterus, no JVD, abdomen no masses; no palpable organomegally; lungs clear, normal chest wall motion; heart no murmur, regular rhythm; legs no edema, symmetric size; skin no rash or cyanosis, fingernails normal. (at least 12 total bullets from two or more areas)
A: 1) HTN, controlled 2) DM II, controlled 3) CAD, controlled (three points on MDM for diagnosis and substituting three chronic medical conditions for HPI)
P: Increase Metformin from daily to BID dosing. (moderate risk for prescription drug management)
Notice in my progress note examples above that each element from history and physical and MDM must meet the minimal element requirements based on the description of the code detailed above. If documentation in any of these three elements fail to meet the minimum requirements, the correct CPT® code is the code based on the element with the lowest level of documentation. In addition, some face-to-face encounters may contain elements whose documentation support a higher CPT® service code individually, but not as a whole, since history, physical AND MDM must all meet minimum thresholds.
USING NEW PATIENT CLINIC CODES IN THE HOSPITAL SETTING
The CPT® medical billing code group 99201-99205 should used by hospitalists and other physicians or non-physician practitioners in the hospital setting under certain circumstances. I have previously discussed all the possible initial encounter codes that could be used in the hospital setting. These new patient clinic and other outpatient visit codes are included as possibilities. I have provided a detailed discussion of that decision tree analysis at the link provided just above. However, I will discuss the pertinent portions of that analysis here.
For patients admitted observation status, the attending physician should choose from the observation group of medical codes 99218-99220 for the initial encounter, 99224-99226 for observation status follow-up codes, and 99217 for observation discharge. Under certain situations, same day admit and discharge billing codes 99234-99236 or critical care procedure codes may also apply too. This is not the case for consultants taking care of observation status patients. What codes should a consultant use in an observation status situation? This is where the correct code decision can get very complicated. Medicare no longer recognizes consult procedure codes. Consultants should pick the appropriate level of service from the new outpatient clinic code group 99201-99205 as their initial encounter, but only IF the patient has NOT been seen previously by the physician or a physician partner of theirs in the same group and exact same specialty and subspecialty within the previous three years. Alternatively, critical care codes can be used instead if documentation supports their use.
If the patient HAS been seen in the last three years by the same physician or partner physician in the same group and exact same specialty and subspecialty, the consultant should use the established patient clinic code group 99211-99215 on their initial date of service and continue to use that code group for all subsequent observation services, including the day of discharge. Remember, all hospital observation CPT® code groups are reserved only for the attending physician. If a patient qualifies as a new patient but clinician documentation does not support any code from the code group 99201-99205 (usually because of the three out of three documentation requirement), then it is appropriate to instead choose a code from the established patient code group (99211-99215) that meets documentation requirements. This guidance has previously been confirmed by Medicare carriers.
The above discussion relates to Medicare because Medicare does not accept consult codes. Other insurances may still accept consultation codes. In those cases, the consultant should chose a level of service from medical code group 99241-99245 (outpatient consult codes) as the initial encounter and then pick a billing code from the established patient clinic codes 99211-99215 for all subsequent care visits, including the day of discharge, while the patient is hospitalized for observation services. If the patient is formally admitted inpatient, the consultant should use the inpatient subsequent care codes 99231-99233 for all subsequent face-to-face encounters.
DISTRIBUTION OF NEW PATIENT OFFICE OR OTHER OUTPATIENT VISIT CODES (99201-99205)
What is the distribution of CPT® code 99203 relative to other levels of service in this medical code group? The chart below was published in May, 2012 by the OIG in a report titled Coding Trends of Medicare Evaluation and Management Services on page 21. As you can see, between 2001 and 2010, the distribution of new patient office visits 99204 and 99205 has shifted higher (an increase of 12% and 4% respectively) while the proportion of level three 99203 has remained constant with no change from 2001-2010. On an absolute basis, of all codes in the group 99201-99205, CPT® code 99203 represented 37% of all services from code group 99201-99205.
Here is data from the most recent 2011 CMS Part B National Procedure Summary Files data (2011 zip file) showing how many CPT® 99203 encounters were billed and the dollar value of their services for Part B Medicare. As you can see in the image below, E/M code 99203 was billed 9,479,315 times in 2011 with allowed charges of $955,752,231.12 and payments of $663,786,846.85.
RVU VALUE
How much money does a CPT® 99203 pay in 2016? That depends on what part of the country you live in and what insurance company you are billing. E/M procedure codes, like all CPT® billing codes, are paid in relative value units (RVUs). This complex RVU discussion has been had elsewhere on The Happy Hospitalist. For raw RVU values, a CPT® 99203 is worth 2.17 total RVUs for facility services and 3.04 total RVUs for non-facility. The work RVU for 99203 is valued at 1.42. A complete list of RVU values on common hospitalist E/M codes is provided at the linked URL. What is the Medicare reimbursement for CPT® code 99203? In my state, a CPT® 99203 pays just over $72 (facility) and just over $100 (non-facility) in 2016. The dollar conversion factor for one RVU in 2016 is $35.8043.
My coding card taught me that I should be billing for the work I'm providing and it has taught me how to document appropriately. You can see many more of my E/M lectures by clicking through on the provided link. If you need bedside help determining what level of care you have provided, I recommend reviewing the pocket card described below.
LINK TO E/M REFERENCE CARD POST
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