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Read MoreCPT Code 99213 — Established Patient Office or Outpatient Visit
CPT code 99213 Summary table:
| Aspect | Summary |
|---|---|
| Description | Office or outpatient visit for an established patient with low-complexity medical decision-making or 20-29 minutes of total visit time. |
| Time of Service | Typically 20 to 29 minutes spent on face-to-face or total care on the encounter date. |
| Documentation | Requires an extended problem-focused history, expanded problem-focused exam, and low-complexity decision-making. Documentation must support the time spent or the decision-making level. |
| Typical Usage | Follow-up for stable chronic conditions, management of minor acute illnesses, routine medication refills, and monitoring stable diseases. |
| Requirements for Billing | Detailed history and exam, documentation of low-complexity decision-making, or total time, medical necessity justification. |
| Reimbursement | Moderate reimbursement rate, covered by commercial payers, Medicare, and Medicaid for medically necessary office visits. |
| Common ICD-10 Codes | Examples include hypertension (I10), type 2 diabetes (E11.9), acute respiratory infections (J06.9), hyperlipidemia (E78.5), and asthma (J45.909). |
CPT code 99213 is an Evaluation and Management (E/M) code used for office or outpatient visits with established patients. It represents a Level 3 visit, involving low medical decision-making complexity or about 20–29 minutes of total patient encounter time.
It is commonly used for follow-ups of stable chronic conditions, minor acute illnesses, or routine medication management.
What Is the Description of CPT 99213?
Type: Office or outpatient visit for an established patient
Complexity: Low-level medical decision-making
Time: 20–29 minutes of total time on the date of the encounter
Documentation: Requires extended problem-focused history, expanded examination, and low-complexity decision-making
Typical visit scenarios include:
- Follow-up for stable chronic illnesses (e.g., controlled diabetes or hypertension)
- Minor acute problems (e.g., mild asthma, UTI, sinus infection)
- Medication refills or routine follow-up assessments
What Are the Documentation Requirements for Billing CPT 99213?
To bill CPT 99213 correctly, documentation must include:
Chief Complaint (CC)
History of Present Illness (HPI)
Review of Systems (ROS)
Past, Family, and Social History (PFSH)
Expanded physical examination of affected systems
Low-complexity medical decision-making, including:
Limited number of diagnoses or treatment options
Minimal data review (labs, imaging, etc.)
Low risk of complications
Alternatively, documentation may be time-based if total time spent (20–29 minutes) is recorded, including:
- Reviewing prior records
- Performing the exam
- Counseling/educating the patient
- Coordinating care
What Are the Reimbursement and Coverage Details?
Coverage: Accepted by Medicare, Medicaid, and commercial insurers for medically necessary visits.
Reimbursement Rate: Moderate — lower than higher E/M levels (99214–99215) due to reduced complexity.
Purpose: Ensures accurate payment for low-to-moderate complexity care while maintaining compliance with payer requirements.
How Much Time Is Typically Spent for CPT 99213?
Typical total time on the date of service is 20–29 minutes, including:
Reviewing records or results
Performing examination and assessment
Counseling or educating the patient
Ordering tests, medications, or referrals
Documenting and coordinating care
What Are the Common ICD-10 Codes Billed with CPT 99213?
Below are commonly associated ICD-10 codes that match the low-to-moderate complexity nature of 99213 visits:
| Condition | ICD-10 Code | Description |
|---|---|---|
| Hypertension | I10 | Essential (primary) hypertension |
| Type 2 Diabetes Mellitus | E11.9 | Without complications |
| Acute Upper Respiratory Infection | J06.9 | Unspecified, uncomplicated |
| Hyperlipidemia | E78.5 | Disorder of lipid metabolism |
| Asthma | J45.909 | Unspecified asthma |
| Back Pain | M54.5 | Unspecified low back pain |
| Hypothyroidism | E03.9 | Unspecified hypothyroidism |
| Generalized Anxiety Disorder | F41.1 | Chronic anxiety condition |
| Vitamin D Deficiency | E55.9 | Nutritional deficiency requiring follow-up |
What is the difference between cpt code 99213 and 99214 ?
The main difference between CPT codes 99213 and 99214 lies in the complexity of the visit, the amount of time spent, and the level of documentation required.
CPT 99213 is used for low-complexity visits with 20-29 minutes spent with the patient. It typically involves a problem-focused history and examination and is appropriate for stable or minor conditions.
CPT 99214 is for moderate-complexity visits requiring 30-39 minutes spent with the patient. It calls for a more detailed history and comprehensive examination and is suitable for patients with multiple or more serious conditions requiring moderate to high medical decision-making.
In summary, 99214 visits are more complex and time-consuming than 99213 visits, reflecting higher medical decision-making and greater risk or number of diagnoses, and this impacts billing and reimbursement accordingly.
Here is a tabular comparison of CPT codes 99213 and 99214:
| Feature | CPT 99213 | CPT 99214 |
|---|---|---|
| Complexity Level | Low to Moderate complexity | Moderate complexity |
| Time Spent | 20-29 minutes | 30-39 minutes |
| Medical Decision Making (MDM) | Low complexity | Moderate complexity with detailed documentation |
| Number of Diagnoses | 1-2 stable or minor conditions | Multiple conditions, new or worsening problems |
| Data Reviewed | Minimal or no labs, imaging, records | Review of labs, imaging or external records |
| Risk of Complications | Low | Moderate |
| History | Problem-focused | Detailed |
| Examination | Problem-focused | Comprehensive |
| Common Usage | Stable chronic or minor acute problems | Multiple or more serious problems requiring adjustments |
| Reimbursement | Lower reimbursement | Higher reimbursement |
What is the difference between 99215 and 99214?
The main difference is the level of medical complexity and time spent with the patient. 99214 is for an established patient with moderate complexity, while 99215 is for an established patient with high complexity, typically involving more severe conditions, more diagnoses, and longer visit times.
Feature | CPT Code 99214 | CPT Code 99215 |
|---|---|---|
Complexity | Moderate | High |
Example Conditions | Routine follow-ups or stable conditions requiring moderate management | Severe cases with significant management needs, such as uncontrolled conditions or a new, serious diagnosis |
Time | Often 30-39 minutes | Typically 40+ minutes |
Medical Decision Making | Moderate medical decision making | High-level medical decision making |
Does Medicare cover 99213?
Yes, Medicare covers CPT code 99213 for established patient office or outpatient visits. It generally applies when the visit involves moderate complexity evaluation and management services, typically taking 20-29 minutes of face-to-face time.
The visit usually includes an expanded problem-focused history, exam, and low-complexity medical decision-making. Medicare recognizes this code for reimbursement when medical necessity and documentation requirements are met.
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