The short version
- 99203 is a level 3 office visit for a new patient. Low-complexity medical decision making, or 30 to 44 minutes of total time on the date of service. Either path on its own.
- New patient means nobody in your group, in your specialty, has provided a face-to-face service in the last three years. That definition is where most 99203 claims actually go wrong.
- 2026 Medicare pays about $118 nationally for 99203, non-facility, against a conversion factor of $33.40 for non-QP clinicians and $33.57 for QPs.
- Office visits were exempt from the 2026 efficiency adjustment that cut work RVUs 2.5% across roughly 7,700 codes. The work RVU for 99203 is unchanged at 1.60.
- The pattern we see in claims data: 99203 gets used as the house default for anyone new. A first visit where you build a problem list from scratch, order labs, and review outside records is a 99204. The spread is $60.
What 99203 actually requires in 2026
History and exam do not determine the level anymore. You document them as medically appropriate and they carry no scoring weight. What sets the level is medical decision making or total time.
By MDM, 99203 is low complexity. Typically one stable chronic problem or two minor ones, limited data review, low risk from whatever you decide to do about it.
By time, 99203 is 30 to 44 minutes of total time on the date of service. That counts your chart review before the visit, the visit, and the note, as long as all of it happens that day. It does not count staff time and it does not count work you do the following morning.
Cross 45 minutes and it is a 99204 on time alone, no matter how routine the problem turned out to be.
Who actually counts as a new patient
A new patient is one who has not received a face-to-face professional service from you, or from another physician of the same specialty and subspecialty in the same group practice, within the past three years. The full rule, and the rest of the new patient code family, is here.
Three places that breaks in a specialty office:
Same group, different provider. Your new associate sees a patient your senior partner saw 18 months ago. Same group, same specialty. That is an established patient, and the visit is a 99213 or 99214, not a 99203.
Subspecialty matters. If two physicians in your group are enrolled under genuinely different specialty taxonomies, a patient can be new to one and established with the other. Payers check this against enrollment, not your letterhead.
Three years is from the service date, not the calendar year. A visit on March 2, 2023 makes the patient established through March 1, 2026.
Billing a new patient code for an established patient is a straight overpayment. It is also one of the easiest things for a payer to find, because they have the same claims history you do.
What 99203 pays in 2026
Medicare’s 2026 conversion factor is $33.40 for clinicians who are not qualifying APM participants and $33.57 for those who are. Both took effect January 1, 2026. At 3.52 non-facility RVUs, 99203 lands at about $118 nationally before locality adjustment.
Two things beyond the rate. The 2026 efficiency adjustment cut work RVUs by 2.5% across roughly 7,700 codes and did not touch office visits — CMS exempted the time-based E/M family, 99202 through 99215. The work RVU for 99203 is still 1.60, the same as last year. Separately, indirect practice expense for facility-setting work was cut in half, which shifts money toward care delivered in your own office.
| Code | Level | Time (total, date of service) | MDM | 2026 national average |
|---|---|---|---|---|
| 99202 | 2 | 15-29 min | Straightforward | ~$75 |
| 99203 | 3 | 30-44 min | Low | ~$118 |
| 99204 | 4 | 45-59 min | Moderate | ~$177 |
| 99205 | 5 | 60-74 min | High | ~$237 |
99203 is the house default, and the default is usually wrong
Here is what shows up in claims data. Practices pick a new patient level by feel, settle on 99203, and use it for nearly everyone walking in the door for the first time.
Think about what a real first visit involves. You have no problem list, so you build one. You order labs or imaging because you have no baseline. You request records from the referring physician and read them. You start or change a prescription. Under the MDM grid, that is data review plus risk, and two of the three elements at moderate makes it a 99204.
The spread is $60 a visit. A provider seeing six new patients a day, defaulting three of them to 99203 when the note supported 99204, is giving back roughly $45,000 a year on documentation that was already good enough.
The fix is not to code up. It is to score the visit against the MDM grid instead of picking a level from habit, and let the number land where it lands.
Five mistakes that turn a clean 99203 into a denial
- Billing 99203 for a patient your partner saw 18 months ago. Same group, same specialty means established.
- Using “30 or more minutes.” The range is 30 to 44. Over 44 is a 99204.
- Scoring history and exam as if it still sets the level. It has not since 2021.
- Counting staff time, or the next morning’s charting, toward total time.
- Defaulting every new face to 99203 without running the MDM grid.
Frequently asked questions
What is CPT code 99203?
A level 3 office or outpatient visit for a new patient, supported by either low-complexity medical decision making or 30 to 44 minutes of total time on the date of service. Either path qualifies on its own.
How much does 99203 pay in 2026?
About $118 nationally under Medicare, non-facility, before locality adjustment. The 2026 conversion factor is $33.40 for clinicians who are not qualifying APM participants and $33.57 for those who are, both effective January 1, 2026.
What is the difference between 99203 and 99204?
MDM complexity and time. 99203 is low-complexity MDM or 30 to 44 minutes; 99204 is moderate-complexity MDM or 45 to 59 minutes. Either path gets you there on its own. The payment difference is about $60 per visit.
Who counts as a new patient for 99203?
A patient who has not received a face-to-face professional service from you, or from another physician of the same specialty and subspecialty in the same group practice, within the past three years. Three years runs from the date of the last service, not the calendar year.
How long does a 99203 visit have to be?
It does not have to be any particular length if you are coding on medical decision making. If you are coding on time, the range is 30 to 44 minutes of total time on the date of service, including same-day chart review and documentation.
Can 99203 be billed with a procedure on the same day?
Yes, with modifier 25 appended to the E/M, and only when the evaluation was significant and separately identifiable from the procedure. Missing modifier 25 is one of the most common dermatology denials.
Is 99203 affected by the 2026 efficiency adjustment?
No. CMS exempted time-based services, including the E/M office visit family 99202 through 99215, from the 2.5% efficiency adjustment applied to roughly 7,700 other codes in 2026. The work RVU for 99203 is unchanged at 1.60.
Can 99203 be used for telehealth?
Yes, subject to the telehealth rules, place-of-service codes, and modifiers in force on the date of service. These have changed repeatedly since 2020, so confirm the current requirements before billing.
This article explains how these codes tend to get paid — it is not coding, billing, or legal advice. Some of the codes here are bundled into the main procedure, or fall into grey areas that vary by payer. Before billing anything in a grey area, confirm it with your own coding and compliance team and the current guidance from the American Academy of Dermatology (AAD), Medicare (CMS), and AMA CPT. When in doubt, don’t bill it.
