Medical Billing Code 99213 is one of the most frequently used evaluation and management codes in outpatient and office settings. It applies to established patient visits that require a moderate level of clinical judgment. You can bill 99213 when the visit requires low-level medical decision-making or when you spend a total of 20–29 minutes on the date of service under the current E/M guidelines.
This blog will explain when and how to use CPT code 99213 properly. And how this code can make a big difference in billing and smoother claims processing. Read more!
What is Medical Billing Code 99213?
Medical Billing Code 99213 is a frequently utilized Current Procedural Terminology code. This code is utilized for an office or other outpatient visit for the evaluation and management of an established patient. These codes are created and updated by the American Medical Association. CPT codes provide a universal language that enables healthcare professionals to clearly convey services to insurance companies.
CPT 99213 Official Description:
Here is the official description directly from the AMA’s CPT guidelines:
“Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and a low level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter.”
The Core Elements of a 99213 Visit:
Code 99213 may look like just another billing number. But behind this code are defined elements that define whether the visit truly qualifies.
The documentation must satisfy the following foundational pillars to accurately bill for 99213. These core components are:
Established Patient Status:
99213 is reserved only for established patients. This means someone who has received professional services from the physician or another physician of the same specialty within the last three years.
Medically Approved History and Physical Exam:
Documentation does not require a specific number of history or exam elements under the current E/M guidelines. But the provider must perform and document what is clinically appropriate for the patient’s condition.
For example:
- Reviewing symptoms related to a chronic condition
- Performing a focused physical exam relevant to the complaint
- Updating medication or treatment history
Low-Level Medical Decision Making (MDM):
The visit must have a low level of medical complexity. The low MDM is determined by evaluating three areas:
- Problems addressed: One or more stable chronic conditions or a minor acute illness
- Data reviewed: Limited data such as reviewing lab results or ordering straightforward tests
- Risk level: Low risk of complications or morbidity
Documentation must support at least two of these three elements to qualify via MDM.
Total Time:
Alternatively, if you are coding based on time rather than MDM, a 99213 requires 20-29 minutes of total time spent on the date of the encounter. This will include not only the time physically in front of your patients but also pre- and post-work with office visit records.
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Why Accuracy is Important:
CPT 99213 is a frequently used code and that’s why getting it right is so crucial. Excessive documentation without proof of medical necessity won’t protect you from an audit.
Knowing these essential components guarantees that the patient’s journey is appropriately reflected in the medical record. While it also keeps the administrative side of the practice running smoothly.
What Does a Typical CPT 99213 Patient Look Like?
An established patient with a minor acute illness and a stable chronic condition is typically the one who qualifies for this level of care. The foundation of primary and specialty care consists of these standard visits.
Common Clinical Scenarios:
A patient visit that qualifies for Medical Billing Code 99213 often includes situations like:
- A patient who is coming back for a six-month checkup regarding their hypertension
- A diabetic patient who needs to change their medication after looking over lab results
- Someone who needs to be evaluated and prescribed medication for a mild respiratory infection
- A patient discussing side effects from an existing medication
- Follow-up care after a recent minor illness or treatment
Identifying the Complexity Level:
The defining characteristic of a 99213 patient is that their condition carries low risk. The visit would probably escalate to a 99214 if the patient’s symptoms were worsening. Or if the physician had to consider a wide array of high-risk diagnostic tests.
When to Use (and When Not to Use) CPT Code 99213:
Choosing the right E/M code often feels like a balancing act. These codes are about matching the level of service to the actual care delivered.
Here is a breakdown of the typical Green Light and Red Light scenarios for 99213:
| When to Use | When Not to Use |
| Established patients only | New patients and first visits |
| Stable chronic conditions | If a chronic condition is worsening |
| Minor acute illnesses | High-risk decisions |
| Low-complexity MDM | Less than 20 minutes or 30+ minutes |
| Total time (20–29 Minutes) | Preventive care |
99213 Documentation Requirements:
Compliant medical billing is based on accurate documentation. The following should be included in your medical record to appropriately support billing code 99213.
- Chief Complaint or Reason for Visit
- Medically Appropriate History and/or Exam
- Problems Addressed
- Data Reviewed or Ordered
- Past, Family, and Social History
- Total Time
- Risk of Management
99213 vs. 99214: A Quick Comparison
One of the common coding questions in outpatient medical billing is whether a visit qualifies for CPT 99213 or 99214. Both codes apply to established patient office visits. The main difference lies in risk and complexity.
Here is a comparison between these two codes:
| Feature | CPT 99213 (Level 3) | CPT 99214 (Level 4) |
| Patient Type | Established patient | Established patient |
| Complexity of MDM | Low Complexity | Moderate Complexity |
| Chronic Conditions | 1 stable chronic illness | Multiple chronic conditions Worsening conditionMore complex issue |
| Data Reviewed | Limited data such as:Basic labs Simple tests | Moderate data like:Multiple tests External recordsIndependent interpretation |
| Total Time | 20–29 minutes | 30–39 minutes |
| Clinical Intensity | Straightforward management decisions | More detailed evaluation and higher clinical judgment are required |
2026 Reimbursement Rates for 99213:
Payment rates for this common established patient office visit vary depending on the payer and geographic factors. Here are typical 2026 reimbursement levels from major payer categories:
| Payer Type | Estimated 2026 National Rate |
| Medicare – Non-Facility/Office | ~$91.85 per visit |
| Medicare – Facility/hospital | ~$65–$66 per visit |
| Commercial Insurance | ~$95–$115 per visit |
| Medicaid (State) | Varies widely |
Modifier Use With CPT Code 99213:
Think of a modifier as a translator for the insurance company. It provides the extra context needed to explain why a service should be paid separately.
- Modifier 25: Significant, Separately Identifiable E/M Service
This is used for a 99213 visit and a minor procedure on the same day. It tells the payer that the evaluation went beyond the usual pre- or post-procedure work.
- Modifier 24:
It is used when an established patient visit occurs during a global surgical period but is unrelated to the original procedure.
- Modifier 95 and 93:
These are used for telemedicine services. 95 is used for real-time audio-video encounters. The 93 identifies synchronous audio-only.
How Paymedics Can Help Ensure 99213 Compliance:
Maintaining compliance for a high-volume Medical Billing Code 99213 requires a system. This is where Paymedics steps in as a strategic partner. We combine advanced AI technology with human expertise to ensure your documentation is audit-proof and your reimbursements are accurate.
Here is how we ensure 99213 compliance:
- AI-Powered Claims Scrubbing
- Specialized E/M Documentation Audits
- Real-Time Benchmarking and Reporting
- Continuous Education and Regulatory Updates
- Seamless EHR Integration
FAQs
Can the 99214 Code be used for patients with a previous visist 5 years ago?
The doctor or a partner cannot use this code if they have not seen the patients in over three years. These guidelines are provided by the AMA.
Is this code only for doctors?
Not at all. The physician is the common term. Nurse practitioners and other qualified healthcare professionals use this code daily to bill for their services.
How is 992123 different from 99212?
CPT 99212 is for straightforward and self-limiting issues. These involve concerns like a quick check on a healing bug bite. While a 99213 involves issues like managing a chronic disease or dealing with an acute illness.
Does the doctor need to spend full minustes with patients?
Not neccessarily. The total time includes all the work you did on that specific date for that patient.
What if the visit only lasts 15 minutes but the case was complex?
You can still bill 99213 if the MDM was low. You only use time if the MDM does not quite reach that level.
Why was my 99213 claim denied as inclusive?
This happens if you perform a procedure on the same day but forgot Modifier 25. It also happens if you bill during a global period without modifier 24.
Does medication management qualify for 99213?
Simple prescription management or minor medication adjustments may qualify. But it depends on complexity and risk.
Can the doctor bill 99213 if a patient received assistance yesterday?
The answer is yes if there is a new medical necessity. But billing two E/M codes in 24 hours may trigger a manual review by the insurance company. They make sure they are not paying for the same service twice.
