Do you bill office visits every day? Are you unsure about CPT 99213? This code is the most common office visit code. About 200 million office visits are billed annually in the US. Medicare pays about $75-110 for this code. Proper coding prevents claim denials worth thousands.
CPT 99213 is for an established patient office visit. This includes a low to moderate complexity visit. The code covers 20-29 minutes of total time. Over 80% of primary care practices use this code daily. Insurance companies audit office visit claims frequently. Wrong level coding causes 50% of visit claim denials.
This guide explains CPT 99213 in simple terms. We show you proper coding and billing rules. You will learn that doc needs too. Facts and data help you bill right. Tables make info easy to understand. Follow these guidelines to get paid faster.
CPT 99213 Code Description
CPT 99213 is for an established patient office visit. This code is for low to moderate complexity. Time-based or medical decision-making is used for coding.
What CPT 99213 Includes
| Component | What It Covers | Doc Needed |
| History | Problem-focused to detailed | Chief complaint documented |
| Exam | Problem-focused to detailed | Relevant body systems |
| Medical Decision | Low to moderate complexity | Assessment and plan |
| Time | 20-29 minutes total | Start and end time |
| Counseling | Face-to-face discussion | Topics discussed noted |
Code Level Comparison
| CPT Code | Complexity | Time Range | Common Use |
| 99211 | Minimal | 5-10 min | Nurse visit only |
| 99212 | Straightforward | 10-19 min | Simple follow-up |
| 99213 | Low-Moderate | 20-29 min | Routine visit |
| 99214 | Moderate | 30-39 min | Complex problem |
| 99215 | High | 40-54 min | Very complex |
Medical Decision Making Elements
Medical decision-making has three components. The number and complexity of problems addressed matter. Amount and complexity of data reviewed count. Risk of complications and management options considered.
Time-Based Coding for 99213
Time-based coding uses total encounter time. This includes face-to-face and non-face-to-face. Time must be clearly documented in the record.
Total Time Definition
Total time on date of encounter only. Includes preparing to see the patient that day. Face-to-face time with the patient and family. Time performing or reviewing tests same day. Time spent on care coordination and referrals.
Time Ranges for Office Visits
| CPT Code | Time Range | Leeway Allowed |
| 99212 | 10-19 min | Can go 2 min over |
| 99213 | 20-29 min | Can go 2 min over |
| 99214 | 30-39 min | Can go 2 min over |
| 99215 | 40-54 min | Can go 5 min over |
Medical Decision Making for 99213
MDM focuses on the complexity of visit decisions. Three elements determine the MDM level always. Two of three elements are needed for the level.
Problem Complexity
| Problem Type | Examples | Points |
| Self-limited minor | Cold, minor rash | 1 point |
| Established stable | Controlled diabetes, HTN | 1 point |
| Established worsening | Uncontrolled diabetes | 2 points |
| New problem, no workup | Simple headache | 3 points |
| New problem with workup | Chest pain needs tests | 4 points |
Data Review Requirements
The amount of data reviewed affects the MDM level. Ordering or reviewing tests counts toward complexity. Reviewing records from outside providers adds complexity. Independent interpretation of tests increases the level too.
Risk Assessment Table
| Risk Level | Examples | Management |
| Minimal | Cold, minor injury | OTC meds only |
| Low | Stable chronic disease | Prescription drug |
| Moderate | Chronic illness exacerbation | New prescription started |
| High | Life-threatening condition | Hospital admission |
Payment Rates for 99213
Medicare and insurance companies pay different rates. Location always affects payment amounts received. Understanding rates helps with money planning.
Medicare Payment by Setting
| Setting Type | National Average | Range by Location |
| Office | $93 | $75-110 |
| Outpatient Hospital | $93 | $75-110 |
| Rural | $88 | $70-105 |
| Urban | $98 | $80-115 |
Commercial Insurance Rates
Private insurance pays 120-200% of Medicare rates, usually. Some plans pay as low as 60%. Contract rates vary by individual insurance company. Verify benefits before seeingthe patient when possible.
Modifiers for 99213
Modifiers provide extra info about the service. Using the right modifiers ensures proper payment amounts. Wrong modifiers cause claim denials always.
| Modifier | Purpose | Payment Impact |
| 25 | Separate E/M same day | Full payment for both |
| 57 | Decision for surgery | Full payment |
| 24 | Unrelated during global | Full payment |
| 59 | Distinct service | Full payment |
Conclusion
CPT 99213 is for an established patient office visit. A proper doc ensures you get paid right. Time or medical decision-making determines the level. Payment rates vary by location and insurance. Avoid common coding and doc errors. Use right modifiers when needed, always. Follow these guidelines to prevent denials completely.
FAQs
What does CPT 99213 include?
Established patient office visit with low to moderate complexity. This requires 20-29 minutes of total time documented. Can also use medical decision-making instead of time. Chief complaint, exam, and treatment plan all included.
How much does Medicare pay for 99213?
Medicare pays about $75-110, depending on location. The national average is approximately $93 for this code. Urban areas pay more than rural areas. Geographic location affects the exact payment amount received.
What is the difference between 99213 and 99214?
99213 is low to moderate complexity visit level. 99214 is a moderate to high complexity visit. 99213 requires 20-29 minutes while 99214 requires 30-39. Medical decision-making complexity differs between the two codes.
Do I need time documented for 99213?
Time doc needed only if using time-based coding. Can use medical decision-making instead of time. If using time, must document total minutes clearly. Time includes face-to-face and non-face-to-face activities.
Can 99213 be billed with procedures?
Yes, if the visit is separate and medically necessary. Must use modifier 25 with the visit code. Doc must support both visit and procedure needs. Each service needs a separate medical need justification.
