Which code is used for a low level new patient exam?

• A. 99202
• B. 99204
• C. 99205
• D. 99203

Answer: (D)

When billing a new patient office visit, the level you choose depends on how extensive the history, exam, and medical decision making (MDM) are, or on the time spent with the patient. For a low-level new patient exam, the level-three E/M code is the best fit because it reflects a thorough yet not overly complex evaluation: a detailed history, a comprehensive or focused exam relevant to the presenting problems, and straightforward MDM. This level captures the typical amount of work involved in a first visit without jumping to higher complexity that would require more time, more extensive testing, or a more complex plan.

Using a level-two code would understate the encounter if the visit involves more than a minimal history and exam, while level-four or level-five codes would overstate the complexity for a low-level case. Documentation should support the level chosen, and some payers may determine level by time if time is the primary factor. In many chiropractic workflows, the level-three code is the appropriate starting point for a standard new patient examination.