CPT 99203 vs 99213 Cost: Are You Being Overbilled for a New Patient Visit?
Quick Answer: CPT 99203 is for new patients. CPT 99213 is for established patients. Both codes represent a standard level 3 office visit. Providers charge up to 30% more for the 99203 code. If you have visited the same practice in the last three years, billing you as a new patient is a coding error. You can appeal this charge and lower your bill.
Real Scenario: The "Three-Year" Trap
Your 99203 Savings Calculator
Enter what you were billed for CPT 99203. We will calculate your potential overcharge based on the fair price.
Your overcharge is moderate. A pre-written appeal letter using the three-year rule will usually fix this error quickly.
Get Your Appeal TemplateThis bill is significantly inflated. Get our full bundle to combat facility fees and new patient coding errors.
Get the Appeal BundleCharges over $1,000 need professional help. ClaimsRank connects you with medical bill advocates who will fight the hospital for you.
Find a Billing ExpertThe Gap: 99213 vs 99203
The only difference between these two codes is your history with the clinic. They both cover the exact same level of medical complexity. Here is the breakdown.
| Criteria | CPT 99213 (Established) | CPT 99203 (New Patient) |
|---|---|---|
| Patient Status | Seen in the last 3 years | Not seen in the last 3 years |
| Typical Time | 20 to 29 minutes | 30 to 44 minutes |
| Medicare Base (2026) | ~$95 | ~$115 |
| Common Error | Code is generally safe if time matches | Billed incorrectly for existing patients |
Medical offices make more money on the 99203 code. They will often default to this code if they update their computer systems or if you see a new doctor in their network.
Red Flag Auditor: 3 Signs of Upcoding
CMS rules state that you are an established patient if you have received services from that exact practice in the last 36 months.
If you see Dr. Smith today, and Dr. Jones next year in the exact same office, you are an established patient. The clinic shares one tax ID.
Sometimes a provider will bill 99203 along with another procedure using a Modifier 25. Your insurance may deny it with a CO-97 code.
Frequently Asked Questions
Related CPT Code Guides
Methodology & Data Sources
Pricing estimates on this page are derived from the following sources:
- CMS Physician Fee Schedule: national unadjusted rates
- AMA CPT® Guidelines: E&M code definitions and documentation requirements
- Geographic Practice Cost Index (GPCI): regional rate adjustments
Last updated: April 19, 2026. Confidence level for comparison pricing data: High. This page does not constitute legal or medical advice.
Sean is an expert in medical claims across E&M, radiology, and surgical billing. He built the ClaimsValidated appeal methodology to help patients fight back and recover overcharges. Learn at SeanWalters.com, find experts at ClaimsRank, or use tools at ClaimsValidated.