A detailed understanding of 99213 is necessary for compliance, billing, and full reimbursement.. In 2024, Medicare reimburses 99213 at around $90.88, and commercial payers utilize it as a baseline for established patient visits with minimal medical decision-making or 20 minutes or more of total interaction time. It is commonly used in basic care, dermatology, psychiatry, and other outpatient settings.
This article explains how to apply CPT code 99213 appropriately, including time and MDM requirements, documentation advice, frequent refusal reasons, and a comparison of related codes. If you’re a healthcare practitioner, coder, or billing specialist, this article will help you use 99213 with precision and confidence, allowing you to decrease denials and increase your income.
What Is the 99213 CPT Code?
The CPT code 99213 is a common evaluation and management (E/M) code for outpatient sessions with established patients. It is crucial for accurately classifying low-complexity contacts and ensuring proper billing, reimbursement, and compliance.
Definition and Code Description
The CPT code 99213 denotes an office or other outpatient visit for an established patient. The visit must include a medically adequate history and/or physical examination, as well as low-level medical decision-making (MDM). Alternatively, if the code is chosen based on time, the provider must demonstrate 20 minutes or more of total time spent on the day of contact.
The American Medical Association (AMA) defines it under CPT rules, and doctors, nurse practitioners, and physician assistants utilize it often for follow-up visits, regular care of chronic diseases, and non-urgent problems. To use this code properly, you must fulfill either the time or the MDM conditions, but not both.
Code Classification
CPT 99213 is designated as a Level 3 established patient office or outpatient visit. It falls between CPT 99212 (lower difficulty, shorter duration) and CPT 99214 (mid complexity, longer time).
Key categorization details:
- Patient status: Established
- MDM complexity: Low
- Time-based coding threshold (2024): ≥20 minutes total time on the day of the encounter
- CMS reimbursement rate (2024): $90.88 under Medicare
99213 CPT Code Documentation Guidelines
Understanding how to correctly document visits billed under the 99213 CPT code is crucial for submitting accurate claims, reducing rejections, and meeting payer criteria. This section explains documentation standards based on time or medical decision-making (MDM), with real-world examples.
Time-Based Billing Criteria
CPT code 99213 might be assigned depending on the total amount of time spent with the patient on the encounter date. This encompasses both face-to-face and non-face-to-face interactions by the billing provider.
Minimum documentation requirements:
- The total time spent must be 20 minutes or greater.
- Time must be explicitly stated in the note (for example, “Total encounter time: 22 minutes”).
- Medically relevant actions, including history review, counseling, documentation, and care coordination, must be included in the time allotted.
Acceptable time-based activities
- Reviewing medical records
- Examining the patient
- Communicating results or next steps
- Updating or reviewing medications or diagnoses
MDM-Based Billing Criteria
Alternatively, 99213 can be assigned for low-complexity medical decision-making.
To qualify:
- One or many stable chronic conditions, or
- An acute and uncomplicated condition
- Limited data review (labs, notes, or test results).
Reimbursement for 99213 CPT Code
Understanding the reimbursement mechanism for CPT 99213 is critical for accurate claim submission and revenue collection. This section discusses major Medicare rates, billing risks, and comparisons to nearby codes.
2025 Medicare Fee Schedule
In 2025, the Medicare Physician Fee Schedule reimburses 99213 at $90.88, based on national averages. This value reflects the code’s low complexity and time barrier.
The key conditions for this rate are:
- 20+ minutes of total provider time (billed by time)
- Low medical decision-making.
- Established patient status.
- Proper documentation supporting the visit components.
Impact of Incorrect Coding
Improper usage of 99213 results in refused or underpaid claims. Common difficulties include:
- Billing for new patients rather than existing ones
- Omitting time spent or MDM information in notes.
- Choosing 99213 when 99214 or 99215 is justified by documentation.
Comparison with 99214 & 99215
CPT 99213 is between 99212 (short visit) and 99214/99215 (more sophisticated treatment). Here is a detailed comparison.
| CPT Code | MDM Level | Time Threshold | 2025 Medicare Rate |
| 99213 | Low | 20 minutes | $90.88 |
| 99214 | Moderate | 30 minutes | $128.16 |
| 99215 | High | 40+ minutes | $180.42 |
Common Mistakes When Using 99213 CPT Code
Incorrect usage of the 99213 CPT code can lead to refused claims, compliance concerns, and revenue losses. This section outlines common paperwork and billing problems seen in clinical practice.
Mistake 1: Using for New Patients
The 99213 CPT code is reserved for established patients. One of the most typical mistakes is using it during a new patient appointment. This issue typically results in automatic denial because it violates CMS or commercial payer billing standards.
To prevent this:
- Confirm that the patient has been seen within the last three years.
- If this is a fresh encounter, use 99202-99205 instead.
- Match the code to the appropriate patient status in the EHR system.
Mistake 2: Insufficient Documentation
Providers frequently fail to capture either the entire time spent or the medical decision-making information necessary for 99213. During audits, payers may reject claims or seek further records.
To repair it:
- If you are invoicing based on time, clearly indicate “Total visit time: 20 minutes”.
- Document MDM aspects such as diagnosis, data review, and risk.
- Include only medically required activities that correspond to the visit level.
Mistake 3: Misuse of Modifiers
Failure to use the appropriate CPT modifiers may affect reimbursement, particularly if operations are done on the same day. Misapplying modifiers such as 25 or 95 might result in underpayment or claim denial.
To avoid this:
- When a separate E/M service is offered on the same day as a procedure, use Modifier 25.
- Use Modifier 95 for telehealth if the payer allows it.
- Always check with the particular insurance company on modifier requirements.
Conclusion
The 99213 CPT code must be used correctly to ensure claim validity, avoid revenue loss, and comply with payer documentation criteria. Misuse due to inaccurate patient status, incomplete time data, or an unsupported MDM frequently results in rejections. Providers can verify compliance and reimbursement by using 99213 based on validated criteria, such as time or low-complexity decision-making. Understanding its location between 99212 and 99214 enables billers to make informed decisions. Each claim must include true service information and accompanying remarks. Precision secures both payment and audit results.
FAQs
What is the 99213 CPT code used for?
The 99213 CPT code is used for outpatient visits with established patients, low-complexity medical decision-making, or 20+ minutes of total provider time.
How much does Medicare reimburse for 99213 in 2025?
In 2025, Medicare reimburses approximately $90.88 for a 99213 visit based on national rates.
Can 99213 be used for new patients?
No, 99213 applies only to established patients within the past three years.
What are common documentation errors with 99213?
Frequent issues include missing time documentation, vague MDM notes, and using the code for the wrong patient type.
When should Modifier 25 be used with 99213?
Use Modifier 25 when a separately identifiable E/M service is performed on the same day as a procedure.
