Everything Providers Need to Know About CPT Code 99213

CPT codes form the foundation of medical billing in healthcare. These standardized codes help providers communicate their services to insurance companies and payers.

Inaccurate CPT coding can delay, reject, or reduce claim payments, harming your practice’s income and patient care.

CPT Code 99213 is a standard code for outpatient visits with established patients. Knowing this code helps providers write notes correctly, get paid fairly, and follow billing rules.

Using CPT 99213 appropriately makes billing easier and lowers the chance of audits and mistakes. Understanding this code helps your practice earn more and ensures patients get care on time without delays.

What is CPT Code 99213?

CPT Code 99213 denotes an office or outpatient visit for a well-known patient. It applies when you conduct an evaluation and management (E/M) service that takes 15 to 29 minutes or involves low to moderate medical decision-making. This code indicates that you focused attention on a patient’s health issues.

Providers classify 99213 under the broader E/M codes, which include history taking, physical exams, and medical decision-making. 99213 is a middle-level code for established patients. It balances more complex visits like 99214 and simpler ones like 99212.

When providers use CPT code 99213:

Providers often use 99213 when:

• Managing long-term illness such as hypertension or diabetes.
• Handling new symptoms that require assessment but are not urgent
• Revising medications or doing routine lab tests
• Conducting follow-up visits to monitor the progress of treatment

This code covers regular office visits, during which the provider reviews the patient’s status and makes moderate decisions about care.

Difference between 99213 and Related E/M Codes

99212: Providers use this CPT code for patients with lower complexity or shorter visits, often involving minor issues or straightforward follow-ups.

99213: CPT code used for the office or outpatient visits with established patients involving a moderate level of complexity. Providers usually use this code for consultations lasting about 15 to 29 minutes, during which they perform an expanded problem-focused history and exam and make low to moderate complexity decisions.

99214: This requires a higher level of medical decision-making and usually involves a more extended visit (30–39 minutes) to address more complex or multiple health problems.

Select the appropriate code based on your medical history, examination, and decision-making documentation. Matching your documentation with the several levels of your bill is crucial.

When to Use CPT Code 99213

Providers use CPT Code 99213 for outpatient visits when they perform a focused to detailed evaluation and management service for an established patient with a medical condition that requires moderate medical decision-making.

Clinical Scenarios /appropriate for 99213

Use CPT 99213 when seeing an established patient for a visit requiring low to moderate medical decision-making. It involves modifying medication, assessing new but non-urgent symptoms, and managing stable chronic diseases.

For example, 99213 is ideal if a patient with controlled diabetes visits for a routine checkup and you analyze test findings to adjust their medication accordingly.

Patient Complexity and Time Considerations

This code usually relates to in-person patient encounters lasting 15 to 19 minutes. While it does not have to be highly complicated, it should not involve making risky choices or reviewing a lot of data. However, 99212 would be preferable if the visit is quick and straightforward. If the time or complexity significantly increases, 99214 would be a better option.

Types of Visits and Providers Using This Code

Providers across many specialties depend on 99213 every day. Primary care physicians, internists, family doctors, and specialists utilize it for office visits, outpatient consultations, and follow-up care. It is common while setting such as:

• Outpatient clinics
• Private practice offices
• Urgent care centers (for non-emergency cases)

Because it is a well-known code, 99213 captures a broad range of patient encounters, making it crucial for many providers to understand.​

Documentation Requirements for CPT Code 99213

When billing CPT code 99213, practitioners must ensure their documentation meets specific requirements. Correct, detailed records are essential to ensuring the level of service and avoiding claim denials or penalties.

Essentia Documentation Elements

To support CPT 99213, your note should include three key elements:

History: Document the patient’s primary concerns, a detailed history of the present illness (HPI), and any related past medical, family, and social history. For 99213, you generally need an extended problem-focused or detailed history.​

Examination: Perform and record a focused or detailed examination of the patient’s condition. It generally involves a focused examination of a specific body area or system, rather than a comprehensive physical exam.

Medical Decision-Making (MDM): Demonstrate moderate complexity in decision-making. It involves assessing multiple diagnoses or management options, evaluating test results, and considering the risks associated with each treatment option. The MDM should reflect clinical judgement that justifies this mid-level evaluation and management (E/M) service.

Time-Based vs. Complexity-Based Coding Criteria

Billers can submit CPT 99213 claims based on the complexity of medical decision-making or the total time spent on the encounter. Here’s what you need to know:

• Complexity-Based: Many providers use this method. It requires documentation of an extended, problem-focused history and examination and moderately complex medical decision-making.
• Time-Based: If therapy or care coordination dominates the visit (more than 50% of the time), you can bill 99213 based on the total face-to-face time—generally, this ranges from 15 to 29 minutes. Note the total time spent and specify that care coordination was the primary focus of the encounter.

Tips to Avoid Documentation Errors

Keeping the following things in mind, you can avoid some errors:

Be Specific and Complete: Avoid unclear statements—clearly document symptoms, lab findings, and your approach.

Match Documentation to Code Level: Your documentation must support complexity level 99213. Over-documentation would not affect the procedure, but under-documentation can lead to denials.

Use Time Stamps When Coding by Time: Use the time-based method to note the start and End times, or total minutes spent.

Document Counseling and Coordination Details: When time is a factor, specify the topics covered and explain why counseling was necessary.

Review Guidelines Regularly: CMS guidelines and CPT codes are updated annually. Stay current to avoid compliance issues.

Billing and Coding Guidelines for CPT Code 99213

Accurate billing and coding for CPT 99213 help ensure timely reimbursement, minimize audit risks, and reflect the true complexity of patient care. Below is an overview of how providers should approach this mid-level evaluation and management (E/M) code.  

Correct Billing Practices for 99213

Providers usually use CPT 99213 for established patients seen in an outpatient or office setting with moderate complexity. To bill accurately with 99213, providers should document a detailed history and examination, demonstrate low to moderate medical decision-making, and ensure the visit lasts about 15 to 29 minutes.

Confirm Patient Status: Providers use CPT 99213 only for established patients—those they or their specialty group have seen within the last three years. Confirming patient status helps ensure accurate billing.

Link to Medical Necessity: Verify that the documented services align with the patient’s condition and justify the level of care.

Use Updated Code Selection Criteria: 

• Medical Decision Making (MDM)
• Total time spent on encounter (15-29 minutes for 99213)

Ensure Supporting Documentation: Your notes must clearly reflect either the moderate complexity of MDM or the specific time provided.

Common Billing Mistakes and How to Avoid Them

Here is a list of frequently billed mistakes with 99213 and how to avoid them:​

Overcoding or Undercoding: Do not bill 99213 for visits that only justify 99212 (low complexity level), and avoid billing 99214 without proper documentation of a higher complexity level. Use verified tools or EHR leads to support accurate code selection.

Insufficient Documentation: If your documents lack MDM elements or specific time details (when coding by time), Pay may downcode or reject the claim.

Wrong Place of Service (POS): Always match the place of service code with the setting—for example, POS 11 for office visits.

Missing or Incorrect Coding Modifiers: If billing with other procedures or telehealth, ensure you use correct modifiers, such as -25 or -95, when needed

Not Updating Coding Systems: Outdated billing software or templates can lead to mistakes. Keep your systems updated with current  E/M guidelines.

Impact of 2021 E/M Coding Updates

The 2021 E/M guideline revisions by the American Medical Association AMA and the Centers for Medicare and Medicaid Services CMS considerably changed how providers select codes for office and outpatient visits. Key changes that affect CPT 99213 include:

• History and exam are no longer key elements in determining code selection. Instead, practitioners focus on MDM or the total time spent on MDM.
• Precise definitions for MDM elements involve the number and severity of problems addressed, the data reviewed, and the risk of complications or impact on treatment decisions.
• Simplifying time documentation involves face-to-face and non-face-to-face time on the service date (e.g., reviewing tests, documentation, communicating results, ordering medications).

These changes reduce the documentation load and allow providers to focus more on the clinical content of the visit.

Payer-Specific Rules (Medicare, Private Insurers)

While CPT 99213 is standardized, every payer may require unique requirements:  

Medicare:

Follows CMS rules and supports 2021 E/M updates.

• Often requires more detailed justification for time-based billing.
• May request additional documentation during audits.

Private Insurers:

• Most major insurers (Aetna, UnitedHealthcare, Blue Cross, etc.) have adopted the 2021 E/M guidelines.
• Some providers may still have pre-authorization requirements or claim edits for specific diagnoses associated with 99213.
• Always review each payer’s policy manual for the latest rules.

Medicaid (State-specific):

• States may vary in implementing Evaluation and Management (E/M) code changes.
• Check state Medicaid websites for updates on CPT 99213 usage and documentation expectations.

Reimbursement and Payer for CPT Code 99213

Providers must understand reimbursement for CPT 99213 to manage revenue efficiently and follow billing rules. Here’s what you need to know about payment ranges and how to maximize your reimbursement.

Typical Reimbursement Ranges and Factors Influencing Payment

Reimbursement Amounts:

Payments for CPT 99213 differ depending on the payer, geographical location, and contract agreements. In most cases, according to official websites like Payerprise:

• Medicare Reimbursements are between $70 and $100 per visit.
• Private insurers often pay more, ranging from $90 to $150, depending on settled rates.
• Medicaid reimbursement tends to be lower and varies from state to state.

Key Factors Influencing Payment:

Geographical Location: Medicare uses the Geographic Practice Cost Index (GPCI), which adjusts payments based on local costs.

Payer Contracts: Each insurer negotiates rates individually, directly affecting the final payment.

Billing Accuracy: Errors in coding or documentation can lead to claim rejections or reduced payments.

Place of Service: Payers reimburse office visits differently than telehealth or hospital outpatient visits.

Use of Modifiers: Accurate use (e.g., -25 for a significant, separately identifiable E/M service) can affect payment.

Strategies to Optimize Reimbursement While Maintaining Compliance

Document thoroughly and accurately: Ensure your documentation justifies the complexity or time-based criteria for CPT code 99213. Complete documentation reduces claim denials and boosts payment.

Use Time-Based Coding When Appropriate: If counseling or coordination of care dominates the visit, track your time carefully to support higher-level billing.

Regular Review Payer Policies: Stay updated on each insurer’s reimbursement guidelines and any changes to prevent surprises.

Leverage Technology: Utilize EHR templates and coding tools to capture all required elements and request any missing documentation.

Avoid Upcoding: Do not bill higher-level codes without proper documentation. Doing so risks audits, penalties, and delayed payments.

Train your Staff: Educate your billing and coding team about the 99213 criteria and common pitfalls to maintain consistent compliance.

Monitor Denials and Appeals: Track claim denials related to 99213 and respond promptly with appeals backed by complete documentation.

Common Challenges and Solutions for CPT Code 99213

Billing CPT 99213 can sometimes result in claim denials, audits, or requests for additional information. Understanding why these issues occur and how to address them helps providers avoid disruptions and maintain a smooth revenue flow.

Common Reasons for Claim Denials and Audits

Insufficient Documentation: The most common reason is that the medical record does not fully support the level of service billed. It might include missing details on history, exam, or medical decision-making.

Incorrect Patient Status: Billing 99213 for new patients instead of established patients can cause denials.

Mismatched Diagnosis and Service: Payers expect the diagnosis to justify the complexity of the visit. A mismatch or missing diagnosis code can trigger rejections.

Time Documentation Issues: When billing based on time, failure to clearly document total minutes or counseling details leads to denials.

Coding Errors: Using inaccurate CPT codes, modifiers, or place-of-service codes can result in claim denials or downcoding.

How to Manage Rejections or Requests for Additional Information

Review the Denial Reasons Carefully: Find out why the claim was denied so you can fix the issues that caused it.

Gather Complete Documentation: Retrieve the patient’s medical record, notes, and other relevant information supporting the service level.

Respond Promptly: Gather additional information or correct claims immediately to avoid delays.

Appeal When Appropriate: If you believe the claim was wrongly denied, file a formal appeal with supporting documents.

Use Clear Communication: When communicating with payers, keep your message concise and factual, referencing guidelines or policies that support your claim.

Best Practices to Reduce the Risk of Denials

Implement a Documentation Checklist: Before billing, use a standard checklist to confirm that all required elements for 99213 are included.

Train Staff Consistently: Keep coders and billers updated on current E/M guidelines and payer policies.

Perform Regular Internal Audits: Periodically review charts and claims to catch and fix errors before submission.

Leverage Technology: Use EHR prompts and coding software that flag incomplete or inconsistent documentation.

Maintain Clear Time Logs: For time-based billing, record and document counseling or care coordination clearly in the patient record.

Conclusion

Accurate Coding for CPT 99213 plays a crucial role in showing the true complexity of patient care, ensuring proper reimbursement, and minimizing the risk of audits or claim denials. Providers must focus on thorough documentation that supports medical decision-making and accurately records the time spent during the visit. As coding guidelines evolve, staying aware of the latest updates is crucial. Regular education and training help maintain compliance and improve billing practices. 

Do not hesitate to seek professional coding support or additional training if any doubt. Investing in expertise can save time, reduce errors, and improve your practice’s financial health.

Are you a provider looking to master CPT Code 99213? 

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