CPT 99213
Established Patient Visit, Low MDM
How it is billed
- Selected by low medical decision-making, or by total time of 20 to 29 minutes on the encounter date — the biller chooses whichever method supports the higher level
- Total time counts the physician's own work on that calendar day: reviewing records beforehand, the visit itself, ordering, counselling and documenting afterwards
- Clinical staff time does not count, and neither does work done on any other day
- Established means the patient received a face-to-face professional service from the same physician, or a same-specialty physician in the same group, within the previous three years
- Billed with modifier 25 when a minor procedure is performed at the same visit and the evaluation went beyond the procedure's inherent assessment
What the record must show
- The note must show which problems were addressed, not merely that they exist on the problem list — an unaddressed chronic condition carried forward does not raise decision-making
- Where time is the basis, the total time and the fact that it was spent on the encounter date should both be recorded; a bare range copied into every note is what auditors look for first
- A medically appropriate history and examination still belong in the record; they no longer determine the level but their absence undermines the visit as a whole
A worked example
An established patient attends for follow-up on hypertension that is stable on current medication, plus a mild seasonal complaint managed with an over-the-counter recommendation. The physician reviews home readings, makes no change to therapy and schedules a six-month review.
That is low decision-making: two stable problems, minimal data, low risk. 99213 is correct, and the visit took 22 minutes including the record review, which supports it on time as well.
The same encounter becomes 99214 only if something in it actually rises — the hypertension is uncontrolled and therapy is changed, or a prescription drug requiring monitoring is managed. Billing 99214 because the visit felt long, without either the decision-making or the recorded time, is the single most common finding in E/M audits.
What decides payment
99213 is the code most practices over-use in one direction and under-use in the other. It is the safe default: reported when the work was genuinely level four because nobody wants an audit, and reported when the work was level two because it is what the template inserts. Both cost money, and only one of them is a compliance problem.
The 2021 restructure of office and outpatient E/M removed history and examination from level selection precisely because bullet-counting had stopped describing physician work. What replaced it — problems addressed, data reviewed, risk — is harder to template and easier to defend, provided the note reflects thinking rather than volume.
Payers profile E/M distribution by specialty. A practice whose established-visit curve sits far from its peers in either direction attracts attention, but the distribution is a screening tool rather than a finding. What settles a review is whether individual notes support the individual codes.
Denials this code attracts
Modifiers that apply
Codes billed alongside or confused with this one
Billed most in — Family Medicine · Internal Medicine · Pediatrics
Terms used here — E/M Coding · CPT Code · Undercoding · Medical Necessity
How we handle it — Medical Coding · Denial Management · Practice Analytics
Primary sources
What the code-set maintainers and payers actually publish about billing 99213.
- Evaluation and Management services guide (opens in a new tab)
Centers for Medicare & Medicaid Services — How E/M level is determined under the current medical decision making and time rules. The reference for any dispute about whether documentation supports a level.
- CPT code set (opens in a new tab)
American Medical Association — Maintainer of CPT. Annual changes to CPT are the most common cause of a sudden, unexplained rise in denials each January.
- OIG Work Plan (opens in a new tab)
HHS Office of Inspector General — What the OIG has said it will audit and when. The clearest available signal of which coding patterns are about to receive attention.
Questions about CPT 99213
An office or outpatient visit with an established patient involving low medical decision-making, or 20 to 29 minutes of the physician's total time on the date of the encounter. It is the mid-level of the five established-patient codes.
20 to 29 minutes of total time on the encounter date. That includes the physician's pre-visit record review, the face-to-face time and post-visit documentation and ordering, but excludes clinical staff time and anything done on a different day.
Decision-making level, or time. 99213 is low complexity or 20 to 29 minutes; 99214 is moderate complexity or 30 to 39 minutes. The usual dividing line in practice is whether a problem was actively managed and therapy changed, rather than reviewed and continued.
Yes, with modifier 25, provided the evaluation went beyond the assessment inherent in performing that procedure. The note has to show separate history, examination and decision-making for the evaluation, or the E/M line adjusts under CO-97.
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