New Patient Office Visit, Low Complexity (30 min)
CPT 99203 covers a 30-minute office visit for a new patient requiring low complexity medical decision making. It is one of the most common new patient codes, used nearly 7 million times per year in Medicare alone. Providers charge an average of $256.96 for this visit, but Medicare pays only $117.57 for the physician fee in an office setting (2.2x markup). Most patients don't realize that a first visit is coded differently than a follow-up, and it almost always costs more.
CPT 99203 at a Glance
- Average provider charge: $256.96
- Medicare physician fee (office): $117.57
- Medicare physician fee (hospital): $71.47 + separate facility fee
- Typical markup: 2.2x over Medicare office rate
- Visit duration: 30 to 44 minutes
- Decision complexity: Low
- Patient type: New (not seen in 3+ years)
- Beneficiaries (2023): 6.9 million
On this page
How the Medicare Rate Is Calculated
Medicare prices every procedure using Relative Value Units (RVUs) across three components, then multiplies by a national conversion factor of $33.4009 (2026). Here is the exact math for a 99203 new patient visit:
| Component | What It Covers | Office (Non-Facility) | Hospital (Facility) |
|---|---|---|---|
| Work RVU | Physician time, skill, and judgment | 1.60 | 1.60 |
| Practice Expense RVU | Rent, staff, equipment, supplies | 1.76 | 0.38 |
| Malpractice RVU | Professional liability insurance | 0.16 | 0.16 |
| Total RVU | 3.52 | 2.14 | |
| x $33.4009 | 2026 conversion factor | $117.57 | $71.47 |
Medicare Rate by State
Medicare adjusts the national rate based on your location using Geographic Practice Cost Indices (GPCIs). The same 99203 visit pays differently in each state, ranging from about $108 in Arkansas to $145 in Alaska (a 34% spread).
Medicare Rate by State (2026)
Medicare adjusts payments by location using Geographic Practice Cost Indices (GPCIs). Select your state to see the adjusted rate.
Sample State Rates (Office Setting)
| State | Medicare Pays | Avg. Charge | Markup |
|---|---|---|---|
| Texas (Austin) | $121.79 | $256.96 | 2.1x |
| California (Los Angeles) | $130.89 | $256.96 | 2.0x |
| New York (Manhattan) | $134.58 | $256.96 | 1.9x |
| Florida (Fort Lauderdale) | $122.51 | $256.96 | 2.1x |
| Ohio | $113.26 | $256.96 | 2.3x |
| Mississippi | $109.15 | $256.96 | 2.4x |
| Arkansas | $108.37 | $256.96 | 2.4x |
| Alaska | $145.26 | $256.96 | 1.8x |
Rates shown are for the non-facility (office) setting using 2026 GPCIs and the $33.4009 conversion factor. The average provider charge of $256.96 is the 2023 national average from CMS utilization data. Actual charges vary by provider.
What Insured Patients Actually Pay for a 99203 Visit
If you have health insurance, you do not pay the provider's full charge of $256.96. Your insurer has a negotiated rate with the provider, typically 120% to 200% of the Medicare rate. For a 99203 visit, that negotiated rate is usually $140 to $235. What you owe depends on your plan design:
| Your Situation | What You Likely Pay | How It Works |
|---|---|---|
| Copay plan (deductible met or N/A) | $25 to $75 | Flat copay per specialist or primary care visit |
| Coinsurance plan (deductible met) | $28 to $47 | 20% of the negotiated rate ($140 to $235) |
| High-deductible plan (deductible NOT met) | $140 to $235 | You pay the full negotiated rate until your deductible is met |
| Medicare Part B | $23.51 | 20% of the Medicare-approved amount ($117.57) |
| Medicaid | $0 to $5 | Minimal or no cost-sharing in most states |
Should You Use Insurance or Pay Cash?
If you have a high-deductible health plan (HDHP) and have not met your deductible, you are paying the full negotiated rate for every visit. For a 99203 new patient visit, this is typically $140 to $235 through insurance. Many providers offer a cash-pay rate of $100 to $175 for the same visit, which can be cheaper.
When Cash-Pay Wins
- You are unlikely to meet your deductible this year (low expected utilization)
- The provider's cash rate is below the insurer's negotiated rate
- You want to see an out-of-network provider without a referral
- You are establishing care with a new doctor and want to compare options first
When Using Insurance Wins
- You are close to meeting your annual deductible
- You expect significant medical expenses later this year
- Your copay is less than the cash-pay rate
- You need the visit documented for insurance continuity of care
Common Billing Problems with 99203
Upcoding from 99202 to 99203
A 99202 new patient visit (straightforward complexity, 15 to 29 minutes) pays roughly $79, while 99203 pays $117.57. That 49% jump creates a strong financial incentive to code at the higher level. If your visit was brief, addressed a single straightforward issue (like a rash or prescription refill), or lasted less than 30 minutes, ask why it was coded as 99203. You can request the visit notes to see documented time and complexity.
Coded as new patient when you should be established
The "three-year rule" determines whether you are a new or established patient. If you have seen any provider of the same specialty in the same group within the last three years, you should be coded as an established patient (99212 to 99215). Some practices incorrectly code patients as new after a provider leaves the group, or when a patient switches to a different doctor within the same practice. New patient codes pay 20 to 35% more, so this error is not trivial.
Surprise new patient classification after a gap in care
If you haven't visited your doctor in more than three years, you will be reclassified as a new patient even though you have a history there. This catches many patients off guard because they consider themselves established. Before scheduling after a long gap, ask the office whether you will be coded as a new patient. If so, expect a longer appointment and a higher charge.
Facility fee on top of the physician charge
If your doctor's office was acquired by a hospital system, your visit may now be billed as a hospital outpatient visit. The physician charge drops from $117.57 to $71.47, but the hospital adds a facility fee of $100 to $300, making the total higher. Check your bill for a separate "facility fee" or "outpatient hospital" line item.
Related Office Visit Codes
| Code | Description | Time | Medicare (Office) | Avg. Charge |
|---|---|---|---|---|
| 99202 | New patient, straightforward | 15-29 min | ~$79 | ~$157 |
| 99203 | New patient, low complexity | 30-44 min | $117.57 | $256.96 |
| 99204 | New patient, moderate complexity | 45-59 min | $177.36 | $395.78 |
| 99205 | New patient, high complexity | 60-74 min | $233.83 | $512.46 |
| 99213 | Established patient, low complexity | 20-29 min | $95.19 | $179.97 |
Frequently Asked Questions
How much does a new patient office visit (99203) cost without insurance?
Without insurance, a new patient visit billed under CPT 99203 costs $175 to $350 depending on the provider and location. The national average charge is $256.96. Many providers offer a cash-pay discount of 20 to 40%, bringing the price closer to $155 to $205. For comparison, Medicare pays $117.57 for this visit in an office setting.
Why does a new patient visit cost more than an established patient visit?
New patient visits require more physician time because there is no existing medical history on file. The provider must take a full history, review outside records, and establish a baseline. CPT 99203 (new patient, low complexity) pays $117.57 compared to $95.19 for CPT 99213 (established patient, low complexity), roughly a 23% premium. The visit also tends to run longer.
Can I be coded as a new patient if I have seen this doctor before?
Yes. If you have not been seen by any provider in the same practice and same specialty within the last three years, you are classified as a new patient for coding purposes. This means returning to the same doctor after a long gap can result in a higher-coded new patient visit. This is a common surprise for patients who assumed they were still established.
What is the difference between 99202 and 99203?
CPT 99202 is a new patient visit requiring straightforward medical decision making (15 to 29 minutes), while CPT 99203 requires low complexity decision making (30 to 44 minutes). The Medicare rate for 99202 is about $79 versus $117.57 for 99203. If your visit was short and addressed a single simple issue, it may be more appropriately coded as 99202.
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