CPT 99213 is one of the most frequently used Evaluation and Management (E/M) codes in outpatient and office-based medical practices in the United States. It represents a mid-level established patient office visit and is commonly billed by primary care physicians, internal medicine providers, family practitioners, and many specialists.
Accurate use of CPT 99213 is essential for compliance, reimbursement optimization, and audit risk reduction. Misuse can result in claim denials, downcoding, overpayment recoupments, or payer audits. This guide explains CPT 99213 using current CMS-aligned E/M rules in clear U.S. English, with clinical and documentation-focused depth.
What Is CPT 99213?
CPT 99213 describes an established patient office or outpatient visit that meets low to moderate medical decision-making (MDM) or is based on 20–29 minutes of total physician or qualified healthcare professional time on the date of service.
This code applies only to patients who have received professional services from the same provider or group within the past three years.
CPT 99213 Official Descriptor
Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and 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.
CPT 99213 Place in the E/M Code Range
CPT 99213 falls within the established patient E/M range:
- 99211 – Minimal services
- 99212 – Straightforward MDM
- 99213 – Low MDM
- 99214 – Moderate MDM
- 99215 – High MDM
It is most often selected when a patient presents with stable chronic conditions or an uncomplicated acute issue that requires evaluation, medication management, or follow-up.
Key Documentation Requirements for CPT 99213
CPT 99213 documentation must align with 2021–present E/M guidelines, which emphasize MDM or time, not bullet-point history or exam counting.
Medical Decision Making (MDM) Criteria
To qualify under MDM, two of the following three elements must meet or exceed the low-level threshold.
1. Number and Complexity of Problems Addressed
Examples include:
- One stable chronic illness (e.g., controlled hypertension)
- Two or more self-limited or minor problems
- One acute uncomplicated illness or injury
2. Amount and Complexity of Data Reviewed
This may include:
- Review of prior notes
- Review of test results
- Ordering basic labs
Low data complexity is sufficient for 99213.
3. Risk of Complications and/or Morbidity
Low risk examples:
- Over-the-counter medication management
- Prescription drug management without significant risk
- Minor treatment decisions with minimal complication risk
Time-Based Billing Option
CPT 99213 may be billed based on 20–29 total minutes spent on the date of service, including:
- Reviewing records
- Performing the exam
- Counseling and education
- Ordering medications or tests
- Documentation
Face-to-face time is not required to bill by total time.
Common Clinical Scenarios for CPT 99213
CPT 99213 is commonly used in the following visits:
- Follow-up for controlled diabetes or hypertension
- Medication refill with clinical assessment
- Mild respiratory infections
- Stable asthma or GERD checkups
- Lab result review with treatment continuation
- Post-hospital discharge follow-up without complications
CPT 99213 vs CPT 99214
This distinction is a major audit focus.
| Factor | 99213 | 99214 |
|---|---|---|
| MDM | Low | Moderate |
| Time | 20–29 min | 30–39 min |
| Problem Complexity | Stable | Worsening or multiple chronic |
| Risk | Low | Moderate |
Upcoding 99213 to 99214 without documentation support is a frequent compliance error.
Reimbursement Overview (General)
CPT 99213 reimbursement varies by:
- Geographic location
- Payer contract
- Facility vs non-facility setting
On average, Medicare reimbursement is moderate and stable, making accuracy and volume significant for practice revenue integrity.
Modifiers Commonly Used with CPT 99213
- Modifier 25 – Significant, separately identifiable E/M service on the same day as a procedure
- Modifier 95 – Telehealth services (when applicable)
- Modifier 24 – Unrelated E/M during postoperative period
Improper modifier use is a leading cause of claim denials.
Telehealth and CPT 99213
CPT 99213 is allowed for telehealth services when:
- Documentation supports MDM or time
- Modifiers and place of service codes are correct
- Payer telehealth policies are followed
Clinical parity rules apply; documentation standards are unchanged.
Unique Clinical Takeaways
1. Patient Stability Drives Code Selection More Than Diagnosis Count
Billing CPT 99213 is less about how many diagnoses are listed and more about clinical stability. A patient with three stable chronic conditions may still qualify for 99213, while a single poorly controlled condition may require 99214. Providers should document disease control status clearly.
2. Medication Management Alone Does Not Guarantee 99214
Prescription refills without dosage changes, side-effect evaluation, or risk assessment often remain within low-risk MDM. Overreliance on “medication management” language without clinical complexity justification increases audit exposure.
3. Follow-Up Visits Are High-Risk for Overcoding
Routine follow-ups are frequently upcoded due to habit. Documentation should explicitly state:
- No symptom progression
- Stable lab trends
- No escalation in treatment
This supports appropriate 99213 use and protects against payer recoupment.
Compliance and Audit Risk Considerations
Common audit triggers include:
- Repeated high-level coding without progression
- Identical documentation across visits
- Time-based billing without time statement
- Modifier 25 overuse
Internal audits and provider education reduce long-term compliance risk.
Best Practices for Accurate CPT 99213 Billing
- Document stability explicitly
- Choose MDM or time, not both
- Avoid diagnosis padding
- Align assessment and plan with MDM level
- Educate providers on updated E/M rules
CPT 99213 and Value-Based Care
In value-based models, accurate CPT 99213 usage supports:
- Risk adjustment accuracy
- Population health analytics
- Care continuity documentation
Under-coding can be as financially damaging as over-coding.
Medical Disclaimer
This article is for informational and educational purposes only and does not constitute medical, legal, or billing advice. Coding and billing decisions should be based on official CMS guidelines, payer-specific policies, and professional medical judgment. Always consult authoritative coding resources or compliance professionals for final determination