CPT 99213 is an office or other outpatient visit for an established patient that requires a medically appropriate history and/or exam and either low medical decision making (MDM) or at least 20 minutes of total practitioner time on the date of the encounter.
For most primary care and specialty practices, 99213 is the everyday follow-up visit: a stable chronic condition, a minor acute problem or a quick recheck. Because it sits between the simple 99212 and the busier 99214, the hardest part is not finding the code but proving the level. Underleveling a real 99214 loses revenue on every claim, and billing 99213 for a visit that only supports 99212 is an audit finding.
This guide explains how low MDM is measured, how the 20-minute rule works, how 99213 differs from its neighbors, when G2211 and modifier 25 apply, and what the note needs to show. Eye care visits may instead use the 92002 to 92014 eye exam codes; see our ophthalmology CPT codes list.
Key Takeaways
- Level 99213 by low MDM or by 20 or more minutes of total time on the date of service, whichever the documentation supports better.
- History and exam must be medically appropriate, but they do not set the level.
- Low MDM needs two of three elements at the low level: problems, data and risk.
- Medicare’s G2211 add-on can be reported with 99213 when the practitioner is the continuing focal point for the patient’s care or manages a serious or complex condition over time.
- Prolonged service codes 99417 and G2212 apply only to 99205 and 99215, never to 99213.
Where 99213 Sits Among Established Patient Codes
| CPT code | MDM | Total time (must be met or exceeded) | Typical visit |
|---|---|---|---|
| 99211 | Not required | No time threshold | Nurse or clinical staff visit, such as a blood pressure check |
| 99212 | Straightforward | 10 minutes | One self-limited problem, such as a mild rash |
| 99213 | Low | 20 minutes | One stable chronic illness or one uncomplicated acute problem |
| 99214 | Moderate | 30 minutes | Prescription drug management or a chronic illness with exacerbation |
| 99215 | High | 40 minutes | Severe exacerbation or a decision about hospitalization |
Since the 2024 CPT update, office visit times are single thresholds with no upper limit. A 28-minute visit still supports only 99213 by time; 30 minutes is needed for 99214. For the next level up, see our 99214 billing guide, and for new patients see the 99203 guide.
How Low MDM Is Measured
Meet or exceed the low level in at least two of the three columns below. A visit with a stable chronic illness and low-risk management qualifies even if no data was reviewed.
| Element | Low level | Examples |
|---|---|---|
| Problems addressed | Two or more self-limited or minor problems; one stable chronic illness; one acute uncomplicated illness or injury; one stable acute illness | Controlled hypothyroidism, uncomplicated UTI, ankle sprain, improving pneumonia |
| Data reviewed and analyzed | Limited: any two of reviewing external notes from a unique source, reviewing a unique test result, or ordering a unique test; or an assessment needing an independent historian | Ordering a urinalysis and reviewing last month’s lab result |
| Risk of management | Low risk of morbidity from additional testing or treatment | Over-the-counter medication, rest and ice, physical therapy referral |
When it becomes 99214. Prescription drug management, two or more stable chronic illnesses, a chronic illness with exacerbation, or a new problem with uncertain prognosis all reach moderate on the problem or risk column. If two columns reach moderate, code 99214.
Using the 20-Minute Rule
Total time counts everything the practitioner personally does for the patient on the date of the visit, face-to-face or not:
- Reviewing records and test results before the visit, on the same day
- Obtaining history, examining and counseling the patient or caregiver
- Ordering tests, medications or referrals
- Communicating with other clinicians when not separately reported
- Documenting in the record
Do not count clinical staff time, travel, or time spent on separately billed services. Write the total minutes in the note; start and stop times are optional.
G2211 and Modifier 25 With 99213
| Code or modifier | When it applies with 99213 |
|---|---|
| G2211 | Medicare visit complexity add-on when the practitioner provides ongoing longitudinal care. Since 2025 it can be paid with a modifier 25 visit only when the other same-day service is an annual wellness visit, vaccine administration or a Medicare Part B preventive service. |
| 25 | The visit is significant and separately identifiable from a same-day procedure or preventive visit, and the note shows the extra work. |
| 95 / 93 | Telehealth by audio-video or audio-only, under payer rules and with the correct POS (02 or 10). |
Do not add modifier 25 by default. If the decision to perform a minor procedure is the only reason for the visit, the E/M is included in the procedure and 99213 is not billed separately.
Documentation That Supports 99213
- State the problems addressed. List each condition and its status, such as stable, improving or worsening.
- Show the data. Name each test reviewed or ordered and any external records read.
- Show the plan and its risk. Record treatment decisions, including over-the-counter or prescription choices.
- Record time when you use it. Write the total minutes and the activities.
- Link the diagnosis. Each problem addressed should carry an ICD-10-CM code that supports the visit.
Payment Basics
Medicare pays 99213 under the Physician Fee Schedule. The amount depends on your payment locality and on whether the visit is billed at the non-facility (office) or facility rate. Use the CMS Physician Fee Schedule Look-Up Tool for your 2026 locality amount, and compare commercial payments with your contracted fee schedule rather than with Medicare.
Worked Example
Scenario. An established patient returns for well-controlled hypertension. The physician reviews a recent basic metabolic panel, orders a repeat in six months and continues the same medication with no dose change. MDM: one stable chronic illness (low), limited data (low), continuation of current therapy without adjustment (low). Code: 99213. If the dose had been changed, prescription drug management would raise risk to moderate, but problems would still be low, so the visit stays at 99213 unless the data or problems also reach moderate.
Worried your E/M levels are drifting? Our medical coding audit services compare your 99212 to 99215 distribution against your documentation and show where levels are lost or overstated.
Frequently Asked Questions
What does CPT 99213 require?
An established patient office visit with a medically appropriate history and/or exam and either low medical decision making or at least 20 minutes of total practitioner time on the date of service.
What is the difference between 99213 and 99214?
99213 needs low MDM or 20 minutes. 99214 needs moderate MDM or 30 minutes. Prescription drug management, a chronic illness with exacerbation, or two or more stable chronic illnesses usually support moderate MDM.
Can G2211 be billed with 99213?
Yes, for Medicare, when the practitioner provides ongoing longitudinal care for the patient. With modifier 25 it is payable only when the other same-day service is an annual wellness visit, vaccine administration or a Part B preventive service.
Do I need to document time for 99213?
Only if you level the visit by time. Then record the total minutes on the date of service and the activities performed. If you level by MDM, time is not required.
Can 99213 be billed on the same day as a procedure?
Yes, with modifier 25, when the visit is significant and separately identifiable from the procedure. Emergency department visits use a different code set; see our CPT 99284 guide.
