New Patient Office Visit – 30 to 44 Minutes

CPT Code: 99203

Description: This code is used for new patient visits that generally take between 30 and 44 minutes. The service includes an expanded history and exam with low complexity MDM.

Key Components:

• History: Expanded problem-focused or detailed
• Examination: Expanded problem-focused or detailed
• Medical Decision Making: Low complexity

Time documentation is important if the total face-to-face encounter (including counseling) falls within the 30–44 minute range.

Documentation Tips:

• Record all relevant history and exam findings in sufficient detail.
• Clearly outline the medical decision-making process.
• Include total time spent to support the code selection when applicable.

Ensure that your documentation meets both current CPT standards and payer-specific requirements.