CPT (Current Procedural Terminology) codes are widely used now in medical bills to maintain universality in the description of medical services rendered to patients. Each CPT code has its own reimbursement rate fixed by every payer, depending on the insurance plan and other factors. Correct billing for these CPT codes is very crucial for healthcare professionals to get reimbursement. Insurance companies also want correct and accurate bills without any extra services mentioned to avoid revenue loss. A complete understanding of these codes and best billing practices can help to achieve the desired roles. Among numerous CPT codes, 99203 is essential to bill for the services provided to the patients present in the outpatient department or office.
In this PCC guide, we will learn the description of CPT code 99203, its billing and reimbursement guidelines, and the key components of CPT code 99203. We will also learn about the common challenges healthcare professionals face during the billing process.
CPT Code 99203 description
99203 code refers to the billing of evaluation and management E/M services provided to the new patients in the office or outpatient visits. This code defines the new patients that require detailed history and examination. Medical decision making (MDM) of low complexity is involved in this evaluation and management service. Time frame is also fixed for 99203 CPT code. Time duration for these types of visits is 30-44 minutes.
A complete understanding of new and established patients is very important in order to differentiate between them and bill 99203 for new patients. New patients are those who have not received any medical service from the same healthcare facility in the last three years. New patients present with new symptoms or diseases and require more time for evaluation as physicians are not familiar with the condition.
While established patients have received medical service from the same facility in the last three years. They require less evaluation time as they present with previous diseases which is familiar to the doctors.
Components of CPT Code 99203
1. Detailed History
Detailed history is the information about the patient which is generated during the visit. There are several sections to it, and it begins with the chief complaints. These are one or two line statements why the patient has presented to the doctor. It may be a symptom, disease or some other health matter that needs to get evaluated.
Now comes the history of presenting illness (HOPI) which includes detailed questions about the symptoms and disease the patient presents with. The onset, duration, association, aggravating factors, relieving factors, progression of the symptom is asked and evaluated to reach a diagnosis.
The Review of Systems (ROS) is another important aspect of the process of history-taking. In this step, the healthcare provider goes through a list of body organs with you and asks if there are any symptoms in each area. Physicians may ask questions about respiratory symptoms, gastrointestinal complaints, and neurological issues. The ROS is expected to elicit any associated symptoms that the patient may not have noticed as a symptom of the disease.
Then the history completes with past, family and social history (PFSH). The past medical history refers to previous health problems, surgeries or hospitalizations. This includes family history of any genetic related disease or condition which may have relevance to the patient’s presentation.
2. Detailed Examination
CPT 99203 needs a comprehensive examination of multiple body systems rather than just the patient’s chief complaint. Physical examination is how the provider assesses information using visual inspection, palpation, and auscultation (using a stethoscope).
The system that is relevant to the symptom is first inspected without touching the body for any visible signs. Then it is touched to feel the abnormalities. Stethoscope is used to hear dull sounds which are not audible to ears. These assessments are done to check for any potential signs indicating the nature of disease. Other organ systems are also evaluated as a quick review to check for any signs. Examination findings should be documented and evaluated by healthcare professionals.
3. Medical Decision Making
Low complexity medical decision-making is done for CPT code 99203. This is the code that you use when your provider has to manage one or two issues, for example a stable chronic condition or an acute non complicated problem.
The decision process depends on less complex factors such as routine lab tests or simple diagnostic exams. There is minimal risk for serious complications or treatment as providers deal with conditions that are not life-threatening. The medical conditions covered by this code can be seasonal allergies or small adjustments in medication dosing to manage a chronic condition.
4. Time Frame
The time factor is also of significant importance to this code, and the proposed time limit for this code should be met. Otherwise, it is invalid to bill the 99203 code. These types of visits for new patients usually take 30-44 minutes. The exact time should be recorded and documented to avoid penalties for violation of regulations.
CPT Code 99203 Reimbursement Guidelines
1. Need For Documentation
It is recommended that each step be noted after the patient presents to the office or outpatient department. First of all, patient demographics like age, name, address, gender, mode of admission, profession, and date of presentation should be noted and documented to keep the health records. Then, physicians proceed with a detailed history and detailed examination. Each point of history, like presenting complaints, history of presenting illness, systematic review findings, and other parts of history, needs to be documented for thorough evaluation and to justify the use of CPT code 99203.
Findings in the clinical examination should also be noted. Management plan is made after history and examination. The lab tests, medical decision making details and time for visit is noted in written form. These are basic documentation guidelines which are universal by each payer. In order to avoid billing irregularities like claim denial and objections, documentation should be done as per rules.
2. Billing Process
In some cases, modifiers are used to confirm that other services took place during the visit along with evaluation and management service. For instance, if a patient walks with multiple complaints that means more than one service. There is a need for different levels of examination. This is beyond the standard services provided in 99203. It can be justified by using modifiers in the medical bills.
CPT code 99203 modifier 25 is the best example in this regard. It is used when another medical service is provided to the patient by the same healthcare provider during the same visit for evaluation and management. It defines that E/M service is separate from another procedure (i.e treating an infection) performed during the visit.
Another key factor in the medical billing is pairing of a CPT code with an ICD-10 diagnosis code. Accurate mentioning of ICD-10 diagnosis codes justify the use of CPT code 99203. Diagnosis codes describe the condition of the patient with which he presents to the healthcare professionals. ICD codes work as indications for the use of 99203. If the diagnosis code does not match the CPT code, then it is definitely going to be rejected. Correct coding also reduces the risk of audits and ensures that services are billed properly.
3. The Reimbursement Rate For 99203
CPT code 99203 reimbursement rate varies depending on certain factors, such as type of payer and geographical location. Medicare and private insurance companies bill for 99203 with medical necessity reports as their primary requirement. The reimbursement rates of Medicare and other payers differ from each other. A complete understanding of and knowledge of rates is important before billing for 99203. Rough estimates of reimbursement rates are:
Type of payer | Reimbursement rate |
Medicare | $109.69 |
Private payers | $112.84 |
Geographical location also affects the reimbursement rate. The rate for each service is defined according to the living cost of that area. It is impossible to reimburse all healthcare professionals at the same rate without considering the type and nature of expenses in each state. Rates are fixed for government plans like Medicare and Medicaid. However, rates for private payers can vary as healthcare professionals negotiate with them and fix rates on their own. Highly skilled healthcare professionals often charge more money to the payers.
4. Avoid Upcoding And Undercoating
This is a very serious challenge, and it can lead to direct claim denial and even termination of billing contracts with the payer. Upcoding is always considered a fraudulent act, whether it is done deliberately or mistakenly. Upcoding is termed as assigning higher code than the original one. For instance, billing CPT code 99205 instead of 99203 for an E/M office visit of 30-44 minutes. 99205 is used for more than 60 minutes of visits, and it is also reimbursed at a higher rate than 99203. Therefore, it is recommended to always hire experts for billing and coding services to avoid such blunders in medical bills.
Undergoing the use of a lower code than the actual one leads to revenue leaks and financial instability. Undercoding is more damaging for healthcare professionals rather than payers. If you are facing continuous billing errors, then you must hire a third-party service. They have an expert billing team that detects potential errors, rectifies the mistakes, and enhances the ratio of claim acceptance. That’s how healthcare professionals can maintain financial stability.
Difference between CPT Codes 99203, 99202, 99204 and 99205
There is a list of CPT codes that bill for evaluation and management services provided to new patients during office visits. It is important to get an understanding of each code and see how they differ from each other. Such information helps healthcare providers to include accurate E/M codes in medical bills.
- Code 99203: It is billed for E/M services rendered to new patients involving time duration of 30-44 minutes. It involves detailed history and examination with low complexity decision making.
- Code 99202: It is a less complex code. It defines a less detailed history and examination with sessions lasting for 20 minutes. There is straightforward decision making involved.
- Code 99204: It defines complicated cases with more detailed history and examination. Moderate decision-making is done during these visits. The time interval for such visits is 45-59 minutes.
- Code 99205: The visit lasts for more than 60 minutes for this code. High level of decision making is done in this code.
Conclusion
Evaluation and management services for new patients are billed by many CPT codes. A thorough understanding of each code is necessary for an effective and smooth billing process. Among the E/M family of CPT codes, 99203 is very important. It bills for E/M services during office visits of 30-44 minutes. There are a few components involved in this code.
A detailed medical history of presenting complaints, a detailed medical examination of the relevant organ system, and decision-making are necessary to justify the use of CPT code 99203. Appropriate documentation is necessary to comply with billing rules and regulations.
Documentation shows the details of each step and justifies the use of code. Documentation can avoid claim rejection and help to undergo internal and external audits. Use of CPT code 99203 modifier 25 describes the other services rendered during the same visit. Modifiers should be used where necessary to generate well-explained medical bills. Reimbursement and billing guidelines need to be followed to keep the billing process legitimate and accurate.
FAQ - People Also Asks
Ninety-nine thousand two hundred three code bills for the evaluation and management services provided to the new patients in the office or outpatient department. The visit lasts for 30-44 minutes for 99203 code. Medical history and examination are performed during this visit, and medical decisions are made regarding the disease.
The reimbursement rate for the 99203 code varies from state to state. It also depends on the type of payer billed for CPT code 99203. Private insurers have more reimbursement rates than the Medicare program. The estimated reimbursement rate for Medicare is $109.69 and $112.84 for private payers. The reimbursement rate for different geographical locations depends on the living cost.
Ninety-nine thousand two hundred three bills for less complex visits, which involve detailed history and examination. Visits last for 30-44 minutes involving less complex MDM. At the same time, the 99204 code refers to more complicated visits that involve moderate intensity of medical decision-making. Visits for 99204 usually last for 45-59 minutes. 99204 is a higher CPT code with a higher reimbursement rate.
Detailed medical history, detailed examination and less complex medical decision making are involved in 99203. Time duration of 30-44 minutes is also necessary for such office visits.