Using CPT Code 99213 for Established Patients

Think about this for a second: you’re assigning a CPT code for an office visit, the patient is an existing one, and you have to determine whether you should use the 99212, 99213, or 99214.

The majority of individuals choose the 99213 by default. The reason for choosing 99213 by default is due to the fact that it provides a sense of comfort and familiarity. However, it is also a middle ground between the two other options (the lower end and the higher end).

The reality of 99213 is that it is not simply a default choice, but rather a specific set of criteria that differentiates itself from both the less intensive level (99212) and the more intense level (99214).

Therefore, we will examine each of these aspects in detail throughout this guide. So, at the end of this CPT Code 99213 Guide you will have a clear understanding of when 99213 applies, when it does not apply, and how to properly document 99213 to ensure that the coding you used is correct and reimbursable.

What is CPT Code 99213 in Medical Coding?

CPT Code 99213 is the mid-level office/visit code for an established patient. It is for a visit that took a little longer than a drop-in or same day appointment, but was not as detailed or complicated as a visit that would be billed as 99214.

➜ For example:

There’s a patient who has high blood pressure and has seen this doctor before. They come in for a follow-up, talk about how they’ve been feeling, review their home blood pressure readings, the doctor checks their vitals, adjusts the medication slightly, and gives some advice about diet and exercise. The visit takes a bit of time, but it’s not very complex. That kind of visit might be billed as 99213.

Understanding CPT Code 99213 Classifications

Understanding how 99213 fits into the bigger picture of coding is helpful to knowing 99213. The categories include:

1). Evaluation & Management (E/M)

CPT code 99213 is categorized under evaluation & management (E/M). The evaluation & management category is a group of codes that the healthcare provider uses when he/she evaluates the patient’s condition and decides what actions to take. 99213 is one of the most frequently used E/M codes, since it addresses the “in-between” visits that are more than a quick check-in, but not as complex as a visit that would be coded as 99214.

2). Office or Outpatient

CPT code 99213 can only be used in an office or outpatient setting. A 99213 code can never be used for a hospital admission. Offices and outpatient settings are typically where primary care providers see patients for follow-up appointments, minor complaints, or continued care.

3). Established Patient

The CPT 99213 can only be billed to patients that are “established”. Established patients have received care from the same physician or other physicians in the same practice in the last 3 years. Therefore, the physician will already have access to a complete history and medical record for the patient, and therefore will spend less time taking a history and documenting the patient’s issues compared to a patient that is being seen for the first time as a new patient. New patient visits are coded 99202-99205.

Medical Decision Making and Time Criteria for CPT Code 99213

This is the core requirement to bill for CPT Code 99213. You may qualify for this code through two different ways:

Method #1 – By Medical Decision Making (MDM)

Medical decision making is the degree of thought and judgment you use while treating the patient.

Low to moderate MDM is required for CPT Code 99213 to qualify for the code. Low to moderate MDM indicates that you have provided some type of care for at least one issue/problem with the patient, modified some existing treatment plans, reviewed some test results, etc., but did not deal with extremely high risk or highly complicated issues.

Some examples of Low to Moderate MDM would include: adjusting a patient’s blood pressure medication, reviewing a single lab result, or determining possible treatment options for a mild infection.

Method #2 – By Time Spent

As an alternative to using the complexity of the decisions as a reference point, you can also qualify for CPT 99213 by meeting the time requirements. The total time spent for the visit must be between 20 and 29 minutes on the date of service.

The total time spent for the visit includes all activities related to the visit:

• Time spent face-to-face with the patient
• Time spent reviewing the patient’s chart
• Time spent documenting the visit
• Time spent coordinating care with other healthcare professionals (if needed)

Regardless of which method you use to satisfy the requirements of CPT 99213, using either Low to Moderate MDM or 20-29 minutes of total time is acceptable to meet the requirements of 99213 CPT code.

Clinical Scenarios That Support CPT Code 99213

You can use the code 99213:

1). When The Patient Is Already Established

CPT code 99213 was created for established patients. In order to utilize 99213, the individual must have previously visited your office as a patient, and you must have their medical history on file.

If the patient is visiting you for the first time, then you cannot use 99213, you must use the “New Patient” codes (99202–99205).

➜ Therefore, when you are coding for an established patient that returned to your office and the visit was moderately involved but not overly complicated, 99213 is the proper code for documentation.

2). When Follow-Up Is Needed For Stable Conditions or Simple New Problems

Code 99213 is used  when a patient with stable hypertension or diabetes comes in for a routine follow-up. You might adjust their medication slightly, or review their progress. Another example would be when a patient presents with a new but uncomplicated issue (e.g., a mild rash or sinus infection), you would treat the issue, but it doesn’t present the level of complexity of a 99214.

3). When Reviewing a Limited Amount of Data

With 99213, you’re reviewing labs, notes, etc. but not deeply. For example, you might review a single lab result and decide to make a slight adjustment. If you’re pulling together a lot of different types of data, coordinating with other healthcare professionals, or making complex decisions, that would be more consistent with 99214.

4). When the Risk Level is Low to Moderate

The risk of complication or morbidity should be low to moderate. CPT 99213 is appropriate when the encounter involves low‑to‑moderate risk medical decision making, such as routine medication adjustments, minor acute care, or stable chronic disease management.

CPT Code 99213 Reimbursement Rates

Reimbursement for CPT 99213 will depend upon the insurance carrier (payer) and the provider’s geographic location. The CPT Code itself is the same, however, the amount you are reimbursed for each visit will differ from one payer to another.

Below are some approximate reimbursement levels for 99213 CPT code and how these reimbursements tend to behave among various payers:

Medicare – Approximately $89-$99 Per Visit

Medicare sets a standard level of reimbursement for CPT 99213. Payments for this service typically fall into the $89-$99 range. Many other carriers set their reimbursement levels relative to Medicare’s. As such, Medicare also adjusts for geographical factors. For example, if a physician practices in a low-cost rural area, he/she may be reimbursed near the bottom of this range, whereas if a physician practices in a high-cost urban area, he/she may be reimbursed toward the top of the range.

UnitedHealthcare – Approximately $92.98 Per Visit

In terms of reimbursement for CPT 99213, UnitedHealthcare generally reimburses at a rate of $92.98 per claim. This reimbursement is generally consistent with Medicare’s rate. However, it may be slightly lower or higher due to UnitedHealthcare’s negotiation of individual fee schedules with providers, as well as its application of geographic or network-based adjustments to final payments.

Blue Cross Blue Shield (BCBS) – Around $105 Per Visit

Typically, BCBS reimburses physicians at a higher rate than Medicare for CPT 99213, with average reimbursement rates ranging between $100-$110 per visit. These higher rates are primarily a result of the contractual agreements negotiated by BCBS with physicians and groups. As a result, BCBS has positioned itself in many markets as a strong commercial payer through its reimbursement of common office visit codes such as 99213 at rates above Medicare’s baseline.

Commercial Payers (General) – Roughly $94-$108 Per Visit

Most commercial payers (e.g., Aetna, Cigna, regional plans, etc.) tend to reimburse CPT 99213 at rates within the $94-$108 range. Typically, commercial payers reimburse at or above Medicare’s rate, with the exact rate dependent on local contract negotiations, network status, and market competition. In particularly competitive markets where several payers are competing for physician participation, rates may be closer to the upper-end of this range.

Modifiers Applicable to CPT 99213

Modifiers are add‑on codes that clarify the circumstances of a 99213 visit. They ensure accurate medical billing by showing when an E/M service is distinct, unrelated, or delivered via telehealth.

Modifier 25

99213−25 → An Evaluation and Management Service (E/M Service) was performed on the same date as a Procedure

Modifier 25 is used when an E/M service is performed by a physician on the same date as a procedure. If a patient has an E/M service performed for a diagnosis of Sinusitis and then undergoes Cryotherapy for a Skin Lesion, the E/M Service is separate from the Procedure and is documented as such. The use of Modifier 25 will ensure that the E/M Service is paid separately and not included in the payment for the procedure.

Modifier 24

99213−24 → An Evaluation and Management Service (E/M Service) related to a Condition which is Not Related to the Surgical/Procedural Visit

Modifier 24 is applied to an E/M Service when that service is provided during a post-operative period. However, the E/M Service is not related to the condition treated surgically/procedure.

For example, a patient has had Knee Surgery performed two weeks prior to presenting at your office for a Hypertension Follow-Up visit, the visit to address the patient’s Hypertension is unrelated to the Knee Surgery. By applying this Modifier you are communicating to the Payer that this visit is Medically Necessary and is not part of the Global Surgical Package. Therefore, this visit will be properly reimbursed.

Modifier 57

99213−57 → An Evaluation and Management Service (E/M Service) that results in the decision for Surgery

Modifier 57 is used when the E/M Service directly leads to the decision for surgery. For example, if a patient presents with Gallbladder Pain and after examination and consultation, the Physician decides that the Gallbladder needs to be removed. The E/M Service is key in determining that surgery is needed. The application of Modifier 57 will allow the E/M Service to be recognized as the determining factor for surgical intervention and avoid denial due to the fact that it is included in the surgical service.

Other Situational Modifiers

In addition to Modifiers 25, 24, and 57 there are other modifiers that could be applied to 99213. However, they would only be applied to an E/M Service that meets the criteria of each Modifier. In most cases, Modifier 59 is not used with E/M Codes and is used to indicate that the services provided were distinct. Modifier 33 is used to indicate a Preventive Service; however, it is less common to see these codes together because the Preventive Visits are usually billed using a separate Wellness Code.

Typical Coding Pitfalls With CPT 99213

The misuse of CPT 99213 due to a misunderstanding or inconsistent use by clinicians resulting in billing errors and compliance issues. Proper documentation of the patients’ condition, as well as their medical decisions and level of risk, is essential for proper usage and reimbursement of the code. Here are common mistakes that occur when applying this code:

❌ Using 99212 When It Should Be 99213 Due to Undercoding

A major reason for undercoding is when you use CPT code 99212 when the patient actually met the criteria for 99213. The most common reasons for this occur due to either excessive caution, or simply having forgotten how much time, or decisions were made in relation to that patient visit.

The issue with using 99212 as opposed to 99213 is that 99212 is designated as a minimal visit. For example, when the physician has only used a few minutes to quickly check an issue, or address a simple, routine concern, or had an encounter that took less than 20 minutes to complete.

If your documentation indicates low to moderate Medical Decision Making (MDM), or 20-29 minutes total time, then 99213 is the appropriate code to use. Undercoding will ultimately devalue your efforts and result in lost reimbursement.

❌ Overcoding and Billing 99213 for Minimal Encounters

Overcoding is the exact opposite of undercoding. It means overbilling 99213 for encounters that are clearly minimal. Overcoding occurs when the provider assumes that most visits qualify as 99213 without reviewing their own documentation first. If the visit is nothing more than reassuring the patient, or consisted of a rapid assessment or review, or the total time was less than 20 minutes, then 99212 is the proper code to assign.

Overcoding carries its own set of risks since insurers can potentially identify claims billed at a higher level than supported by the documentation provided. In extreme cases, repeated instances of overcoding may lead to the insurer flagging the claims for repayment, or audit the claims for potential abuse.

❌ Documentation is Too Ambiguous or Incomplete 

Documentation gaps are one of the most common mistakes with 99213. Notes that don’t clearly show time or the components of MDM weaken your claim. Typical misses include failing to record total time, writing vague phrases like “labs reviewed”, leaving out risk statements, or not assessing each problem addressed. Without this detail, insurers may deny the claim or downcode it to 99212.

Be specific but concise-show exactly what you did and why.

❌ Mix Up Time and MDM Without Clarity

Confusion between time and MDM happens when healthcare providers try to use both pathways but don’t fully document either. Remember, you only need one route to justify 99213:

• 20-29 minutes of total time,

OR

• Low to moderate medical decision making.
• The common error is writing partial time (“spent time with patient”) and partial MDM, but neither is complete enough to support the code. This leaves the note vulnerable to denials.

FAQ’s

What type of patient issues would usually qualify for 99213?

The best use of 99213 is for visits where the patient’s issues are stable/uncomplicated. Consider a controlled hypertension condition, an acute asthma flare-up that doesn’t warrant further testing, a mild skin rash etc. The moment you consider a complex, unstable, or multiple condition; you’re probably ready to move into 99214 territory.

How does 99213 differ from a “Quick Check” visit? 

A Quick Check (no real decision making) or under 20 minutes is a 99212. 99213 requires either 20-29 minutes of total time or Low-Moderate Medical Decision Making. If you are making a decision such as adjusting medication, reviewing labs, or treating a minor acute condition, that is enough to support 99213.

What is the biggest red flag for auditors when auditing 99213 claims?

Auditors commonly identify overcoding minimal visits as the most common Red Flag for audits of 99213 claims. If the documentation of your visit only states “reassurance” or a very short encounter, but you bill 99213, the claim is more than likely going to be flagged. Auditors are looking for clear evidence of either time or MDM; general statements such as “reviewed labs,” or “patient stable” are insufficient.

Can 99213 be used for follow-up after a hospital discharge?

Yes, if the follow-up visit is conducted in the office or via telemedicine and meets the requirements. However, if the post-discharge visit is specifically for Transitional Care Management (TCM), you should use the TCM codes (99495 or 99496). Use 99213 when the post-discharge visit is routine and does not involve the higher level of complexity of TCM.

Does counseling time count toward 99213? 

Yes. If you are billing based on time, counseling and patient education are counted towards the 20-29 minutes total time. Be certain to document what was discussed during the counseling session; for example, “Discussed diet changes for cholesterol management, discussed medication adherence.”

How does payer variation affect reimbursement of 99213?

Medicare establishes the benchmark (~ $90-$100 in 2025); however, Private Insurers can pay more or less depending upon contract. For example, BCBS commonly pays more; whereas, UnitedHealthcare generally pays closer to Medicare rates. Always check your local Fee Schedule, reimbursement can vary based on Region/Payer Agreements.