CPT Code 99213 is one of the most commonly used evaluation and management (E/M) codes in outpatient medical settings. It represents a moderate level of medical decision-making and is typically used for established patients. If you work in a primary care practice, internal medicine, or even behavioral health, chances are you bill this code regularly.

Understanding the requirements and correct use of 99213 can help avoid claim denials and ensure proper reimbursement. In this blog post, we’ll break down what 99213 covers, when to use it, and how it compares to other E/M codes.

What Is CPT Code 99213?

CPT 99213 is used for office or outpatient visits involving established patients. This code indicates that the encounter includes a moderate level of complexity. It is one of the go-to codes for follow-up visits, particularly when the patient has ongoing concerns or needs review of lab work and mild adjustments to their care plan.

According to the 2021 E/M guidelines, this code may be based on either time or the complexity of medical decision-making. If billing based on time, the provider should have spent between 20 to 29 minutes in total on the encounter. This includes both face-to-face time and any relevant work performed on the same day outside the actual visit.

When Should You Use CPT 99213?

Providers typically use 99213 when managing stable chronic conditions or addressing straightforward, new problems. If a patient presents with controlled hypertension and the visit includes a medication refill, a brief discussion of blood pressure readings, and minimal lab work, 99213 may be the most appropriate code.

Even if the patient has multiple chronic issues, if those conditions are not worsening or changing significantly, the visit may still fall within the 99213 category. The level of medical decision-making should remain low in order to qualify.

The patient’s symptoms, history, exam, and provider work must align with the criteria for this code.

Documentation Requirements

To justify 99213, providers can document either the time spent or the complexity of decision-making involved. When using the time-based approach, total encounter time should fall within the 20 to 29 minute window. This includes both the face-to-face interaction and any related work on the same day, such as reviewing test results or updating care plans.

If billing based on complexity, the visit must involve medical decision-making of low complexity. This could mean addressing two minor issues or managing one chronic but stable illness. The documentation should clearly support the work done and show the necessity for this level of service.

Make sure to record enough detail to support this level of service. Incomplete notes or vague MDM could lead to downcoding or claim denials.

Reimbursement and Payer Insights

CPT 99213 typically reimburses between $75 and $95, depending on the payer and geographic region. Medicare and most commercial insurers recognize this code. However, reimbursement can vary slightly by contract.

Proper use of this code can significantly impact a provider’s revenue cycle. Billing too high could lead to audits, while billing too low leaves money on the table.

Common Mistakes to Avoid

One common error is using 99213 for new patients. This code is strictly for established patients, and using it otherwise can lead to denials. Another frequent mistake is underdocumenting the work performed, especially when billing based on decision-making. Even if the provider spends adequate time or effort, if it is not reflected in the record, the code may not be supported.

Lastly, when billing based on time, it is important to note the total time accurately and include all relevant tasks completed that day. Sloppy time documentation can trigger audits or reimbursement issues..

FAQ: CPT Code 99213

What type of visit qualifies for CPT 99213?
A visit involving moderate problems, stable chronic conditions, or time-based services lasting 20 to 29 minutes for an established patient.

Can I use CPT 99213 for telehealth?
Yes. Many payers, including Medicare, allow 99213 to be billed for telehealth visits as long as the requirements are met.

Is 99213 only for doctors?
No. Nurse practitioners, physician assistants, and other qualified healthcare professionals can bill this code if they meet documentation standards.

How is it different from CPT 99214?
99214 is used when the visit involves more complex decision-making or longer time. 99213 is for moderate-level services.

How much does CPT 99213 reimburse?
Depending on payer and region, it usually reimburses between $75 and $95.