In healthcare billing, every patient interaction must be translated into a standardized code to communicate the services provided. This process utilizes Evaluation and Management (E/M) codes, a subset of Current Procedural Terminology (CPT) codes, which classify office visits based on the complexity of the work performed. These codes provide a uniform system for describing the amount of physician time and resources required for a patient encounter. The system ensures the billed amount accurately reflects the cognitive effort and risk associated with the care delivered.
Characterizing the Level 3 Visit
A Level 3 office visit is represented by CPT code 99203 for a new patient and 99213 for an established patient. This level sits in the middle of the five-tier complexity scale, signifying a substantial but not overly demanding amount of provider work. Level 3 is classified as Low complexity, contrasting with straightforward Level 2 visits and moderate-to-high complexity Level 4 visits. Code 99213 often serves as the “workhorse” of primary care due to the frequency of routine follow-ups requiring medical judgment.
For an established patient, a Level 3 visit requires 20 minutes of total time spent by the physician or qualified healthcare professional on the date of the encounter. For a new patient, the required time is 30 minutes, reflecting the additional effort needed to establish a comprehensive medical history. The selection of this code depends on meeting specific criteria for either the total time spent or the level of Medical Decision Making (MDM) involved. If MDM is the determining factor, the visit must meet the requirements for Low complexity.
How Medical Decision Making Determines the Level
The primary method for determining the appropriate E/M level is assessing the complexity of the Medical Decision Making (MDM) required during the visit. MDM is evaluated across three distinct components, and the provider must meet or exceed the requirements of at least two of the three components to qualify for a specific level. For a Level 3 office visit, the MDM must be classified as Low complexity.
Components of Low Complexity MDM
The three components are the number and complexity of problems addressed, the amount and/or complexity of data reviewed and analyzed, and the risk of complications associated with patient management.
The first component, problems addressed, meets the low complexity threshold by managing two or more self-limited or minor problems, or addressing one stable chronic illness. An example is a patient seen for mild seasonal allergies and a stable, well-controlled case of high cholesterol.
The second component, complexity of data reviewed, is met by activities limited in scope. This includes ordering or reviewing one unique type of diagnostic test, such as a basic metabolic panel or a chest X-ray, or reviewing documents from an external source.
The final component, risk of complications, is considered low when the potential for harm from the patient’s presenting problem or the management plan is minimal. This level of risk is met when the provider manages an acute uncomplicated illness or injury, such as a simple sprain or cystitis. If a provider meets the criteria for low complexity in two of these three areas, the visit qualifies as a Level 3.
Real-World Examples of a Level 3 Appointment
Many common clinical scenarios fall into the Level 3 category because they align with the requirements for low complexity MDM. A typical example is a follow-up visit to manage a single, stable chronic condition, such as Type 2 diabetes that is well-controlled on its current medication regimen. The physician assesses the patient’s current status and confirms the existing treatment plan remains appropriate, constituting a low complexity problem.
Another frequent example is a new patient visit for an acute, uncomplicated ailment, such as an adult presenting with symptoms of a sinus infection without systemic involvement. The provider performs an evaluation, orders a single diagnostic test if necessary, and prescribes a standard course of antibiotics. This satisfies the low complexity requirements for problems and risk. These visits require a focused assessment and decision-making process that is more than minimal but does not rise to the level of moderate complexity.