CPT Code 99203: New Patient Office or Other Outpatient Services, Level 3 - Chirotouch
October 14, 2023 by ChiroTouch Team Article Billing, Coding
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In this quick reference guide to CPT code 99203, we answer frequently asked questions from our community of chiropractors. Follow us for other articles in our ongoing series, courtesy of ChiroTouch, the cloud-based EHR designed specifically for chiropractors. 

About CPT Code 99203: New Patient Office or Other Outpatient Services, Detailed, Low Medical Decision-Making, Low to Moderate Severity

CPT code 99203 pertains to a new patient office or other outpatient visit for evaluation and management (E/M) services. It is classified as a level 3 E/M service, denoted by the last digit of the code. This code involves three key components that you should keep in mind when billing:

  • Detailed history. Gathering comprehensive information about the patient’s current health concerns, past medical history, family history, and a review of systems.
  • Detailed examination. Conducting a thorough physical examination, which may include specific chiropractic tests or maneuvers, covering multiple organ systems or body areas.
  • Medical decision-making of moderate complexity. Making decisions about diagnosis, treatment plans, and prognosis based on a detailed understanding of the patient’s condition.

If the patient encounter included all of the above, this encounter is a good candidate for billing code 99203. Visits billed to 99203 typically take around 30 minutes, but time shouldn’t be your deciding factor when billing — the complexity of the services provided takes precedence.

Category or Type of Service

CPT code 99203 falls under the category of Evaluation and Management (E/M) services. This code is specifically for new patients, indicating that the patient has not been seen by the provider or another provider in the same specialty within the same practice in the past three years.

Billing Interval

Typically billed per encounter, code 99203 is intended for visits of moderate complexity, generally taking 30-44 minutes. For encounters of lower complexity, consider code 99202, while higher-complexity cases may warrant codes 99204 or 99205.

When Should Chiropractors Use This Code?

Use CPT code 99203 for new patient office or other outpatient visits only when you can answer yes to the following questions:

  • Did you take a detailed history, discussing multiple areas, and possible underlying issues?
  • Did you perform a thorough physical examination looking at various organ systems or body areas that may have specific chiropractic tests or maneuvers?
  • Did you have to make moderate complex medical decisions, such as a diagnosis, a detailed treatment plan, and prognosis based on a thorough review of the patient’s condition?

When deciding between different E/M codes, consider both the time involved and the complexity of the care provided, with complexity being the primary factor.

When Should Chiropractors Not Use This Code?

Chiropractors should avoid using CPT code 99203 for:

  • Established patient visits. This code is specifically for new patients. Established patients should be billed using a code from the series 99211-99215.
  • Routine chiropractic manipulative treatment (CMT) sessions. CMT is a distinct service and should be billed separately. If an E/M service is provided along with CMT, ensure it is distinctly identifiable from routine CMT sessions.
  • Extensive counseling or discussions. If a visit primarily involves extended discussions about lifestyle modifications, pain management strategies, or chronic disease management, consider a code appropriate for counseling and cognitive services.

Check these against what you’ve done for the patient to make sure you’re using the right code.

Which Modifiers Can Be Used With CPT Code 99203?

Modifiers play a crucial role in coding accuracy. For CPT code 99203, consider the following modifiers:

  • Modifier 25. Signifying a separate and distinct E/M service on the same day as another procedure or service.
  • Modifier 59. Indicating that a procedure or service was distinct or independent from other services performed on the same day.
  • Modifier AT. Used to signify that a service or procedure was performed for an acute or chronic subluxation. This modifier is mandatory for 99203 encounters billed to Medicare.
  • Modifier 95. Signifying that the E/M service was delivered via interactive audio-video telecommunications technology.
  • Modifier GT. Also used for telehealth services, more common in cases where insurance providers have not yet universally accepted modifier 95.

Always review payer-specific guidelines when using modifiers to keep your billing accurate and compliant.

What Are the Billing Guidelines and Documentation Requirements Specific to This Code?

To accurately bill and document CPT code 99203, chiropractors should be aware of the following guidelines and requirements:

  • Frequency of use. Billing code frequency may vary based on the patient’s insurance plan. Confirm billing frequency limits for this CPT code and similar codes with each patient’s insurance carrier before submitting claims.
  • New patient status. A new patient-provider relationship must be established for this code to apply. Ensure documentation supports the classification of the patient as new.
  • Face-to-face encounter. A face-to-face encounter, either in person or via telehealth, is necessary. Phone services should be billed to a different code.
  • Care provided. Some evaluation and management of the new patient must occur during the visit. Document a clinical need, provide care, and note decision-making regarding the treatment plan.
  • Separate billing. If additional chiropractic services are provided on the same day, 99203 must be billed separately using modifier 59.

A review of documentation can help you make the right billing decisions and included documentation should be clear, legible, and specific, demonstrating the complexity of the encounter and signed and dated by the chiropractor providing the service.

Common Mistakes Made Specific to CPT Code 99203

Avoid these common mistakes when using CPT code 99203:

  • Overutilization. Use code 99203 only for new patient visits involving detailed history, examination, and moderate complexity. Avoid using it for routine services.
  • Using it for established patients. Established patients should be billed using the appropriate codes for established patient visits.
  • Time-based billing. While time is an important factor, the complexity of E/M elements should be the primary driver for this code.
  • Limited or unclear documentation. Provide specific details that accurately reflect the level of complexity encountered during the visit.
  • Inconsistent documentation. Make sure documentation consistently reflects the moderate level of E/M services provided, avoiding inconsistencies between time spent and documented complexity.
  • Misunderstanding payer policies. Double-check payer-specific requirements and limitations for using 99203 to ensure compliance.

Potential Audit Triggers Specific to This CPT Code

Be aware of potential audit triggers associated with CPT code 99203:

  • Inconsistent use of time. Billing 99203 uniformly for all new patient visits can raise suspicion. Document the actual level of E/M elements, not just time spent.
  • Lack of supporting documentation. Incomplete or vague documentation of history, examination, and medical decision-making can cast doubt on the justification for using 99203. Provide clear evidence supporting the moderate complexity level.
  • Inadequate MDM complexity. If the documented medical decision-making lacks complexity, auditors may question the use of 99203. Demonstrate a high level of clinical reasoning in your documentation.
  • Billing for bundled services. Review coding guidelines and payer policies to avoid billing for services already included in 99203.
  • Frequent use for chronic conditions. Excessive use without evidence of monitoring or adjustments for chronic conditions can attract scrutiny. Document ongoing management in each visit.

Carefully reviewing your documentation and reviewing these triggers before billing can help you head off audits.

What Can I Do to Improve the Accuracy and Efficiency of My Practice’s Billing and Coding Processes?

Enhance your practice’s billing and coding processes with these actionable steps:

  • Regularly review billing and coding practices to identify and rectify potential errors.
  • Keep on top of changes to billing and coding regulations to ensure compliance with current standards.
  • Consider switching to cloud-based EHR and practice management software, such as ChiroTouch, tailored for chiropractors to streamline and enhance your billing and coding processes.

By implementing these measures, chiropractors can enhance the accuracy and efficiency of their billing and coding practices, minimizing claim denials and supporting optimal patient care.

ChiroTouch Helps You Avoid Red Flags

Did you know that insurance carriers actively mine chiropractic billing documents for red flags? Flagged practitioners face a higher chance of audits, demands for more documentation, and other problems.

Streamlined billing, and payment clearinghouses will help you avoid the “red flags” insurers will raise as they mine their data and study your billing patterns.

Read our blog post Chiropractic Billing Red Flags: What Is External Data Mining? to learn more about data mining, the problems that are most likely to make you stand out, and how to avoid them.

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