What is the recommended billing level for a new patient in a clinic to establish care with a provider?

Billing Level for New Patient Establishing Care

For a new patient establishing care in a clinic, bill CPT code 99203 (30-44 minutes or low complexity medical decision-making) as the standard baseline level, unless the visit is exceptionally brief or complex. 1

New Patient Visit Code Selection

The appropriate billing level depends on either total time spent or medical decision-making (MDM) complexity—you should calculate both and bill whichever yields the appropriate level supported by your documentation. 1

Time-Based Coding Thresholds for New Patients

• 99202: 15-29 minutes total time OR straightforward MDM 1
• 99203: 30-44 minutes total time OR low complexity MDM 1
• 99204: 45-59 minutes total time OR moderate complexity MDM 1
• 99205: 60-74 minutes total time OR high complexity MDM 1

Why 99203 is the Standard for Establishing Care

Most new patient visits to establish care naturally meet 99203 criteria because:

• Obtaining a comprehensive medical history, reviewing previous records, and coordinating initial care planning typically requires 30-44 minutes 1
• The presence of multiple chronic conditions requiring assessment, or even undiagnosed problems with uncertain prognosis, qualifies as low to moderate complexity MDM 1
• Care coordination activities, including reviewing outside records and establishing treatment plans, contribute to both time and MDM complexity 1

Medical Decision-Making Complexity Assessment

To determine MDM level, you must meet 2 out of 3 elements at a given complexity level: 1

1. Number/complexity of problems addressed (must be actively addressed, not just listed) 1
2. Amount/complexity of data reviewed (independent interpretation, discussion with external providers, or review of records) 1
3. Risk of complications (undiagnosed new problems with uncertain prognosis = moderate complexity) 1

Common Pitfall to Avoid

Do not use outdated 2013 time thresholds—the 2021 guidelines significantly changed time requirements and now allow billing based on total time spent on the date of encounter, not just face-to-face time. 1

Documentation Requirements

Your documentation must include: 1

• Clear statements of problems addressed during the visit 1
• Risk assessment for any conditions identified 1
• Total time if using time-based coding 1
• Medical decision-making rationale to support your chosen code level 1

Practical Billing Strategy

Calculate both methods and choose the higher supported level: 1

1. Document total time spent on the encounter (including chart review, care coordination, documentation) 1
2. Assess MDM complexity using the 2-out-of-3 element rule 1
3. Select whichever method (time vs. MDM) yields the appropriate code level that your documentation supports 1

Special Consideration for Preventive Care

If the visit is purely for routine wellness/preventive care without addressing active problems, use dedicated preventive care codes instead of standard office visit codes. 1 However, if you address both preventive care and active medical problems, you may bill both the preventive code and an appropriate E/M code with modifier -25. 2