What is a 99203 for E and M Coding?

For a physician, nurse practitioner or physician assistant to be compensated for the services they provide to a patient they must correctly document the events that occurred in the room.  While most medical practitioners document the items, they feel are pertinent, however, CMS has specific criteria that must be documented for each level of service.

The E and M code 99203 is the specific code for a new patient Level 3 patient and is used more frequently than the 99202, in my opinion, it is used more often than it should because the risk level of the patient is rarely low risk.  Also, much like with the 99202, for a new patient visit, most practitioners will complete a comprehensive history and exam at a minimum and in my mind, this should be done.

The items needed to code for this Level of service are made up of the 3 components of the progress note.  For a new patient all 3 components must be met.

1.) History-

  1. History of present illness- Duration, location, severity, modifying factors, associated symptoms, context, quality, and timing

  2. Past medical family and social history

  3.  Review of Systems – 14 recognized systems

  • Constitutional (e.g., fever, weight loss)

  • Eyes

  • Ears, Nose, Mouth, Throat

  • Cardiovascular

  • Respiratory

  • Gastrointestinal

  • Genitourinary

  • Musculoskeletal

  • Integumentary (skin and/or breast)

  • Neurological

  • Psychiatric

  • Endocrine

  • Hematologic/Lymphatic

  • Allergic/Immunologic 

2.) Exam- The physical exam component is comprised of 

  • Constitutional (e.g., vital signs, general appearance)

  • Eyes

  • Ears, nose, mouth, and throat 

  • Cardiovascular 

  • Respiratory 

  • Gastrointestinal 

  • Genitourinary 

  • Musculoskeletal 

  • Skin 

  • Neurologic

  • Psychiatric 

  • Hematologic/lymphatic/immunologic

3.) Medical Decision Making

  1. Diagnosis

  2. Treatment options- Medications, referrals, splints, etc..

  3. Data review – Old records, labs, medical tests, imaging, etc…

  4. Level of Risk – Minimal, low, moderate and high

For a new patient 99203 the following items must be met for each of the three components.

  • History – Four element of HPI, two systems reviewed, and one PMFSH reviewed

  • Exam- Minimum of two systems (with one being detailed) and a maximum of seven systems

  • Low-risk complaint and needs to have either: two diagnoses, two treatment option or two data reviews.

Example: 99203

51 yo male here for the complaint of moderate chronic seasonal allergies for 2 years and has used OTC Flonase with mild relief.  The patient states the symptoms are worse in the fall.

PMFSH – one reviewed

ROS – Ear, nose throat - positive for nasal congestion

            Respiratory – Positive for cough

 

Exam – General – well developed well-nourished

 

ENT – clear nasal discharge noted, bilateral tympanic membranes without erythema, posterior pharynx with post nasal drip noted

 

Diagnosis – 1.)  Seasonal allergies

                     2.) Cough

  • (HPI components)

  • (ROS systems)

  • (Systems examined ENT detailed)

As you can see from the above example or a 99203 the complexity of the patient and amount of exam required are very simple for the seasoned practitioner.

The other option for billing for Evaluation and management codes is the unit of time.  For a 99203 the practitioner must spend at least 30 minutes face to face with the patient and half of the time spent counseling the patient on treatment, lab results, and planning.  All these components should be documented.