The 99213 CPT code is one of the most frequently billed E/M codes, and also one of the most misused. Even small documentation gaps or misunderstandings around time, medical decision-making, or patient status can lead to claim denials, delayed payments, or compliance issues. If you bill established patient office visits, getting 99213 right is not optional; it’s essential.
In this article, we break down exactly when to use CPT code 99213, what documentation insurers expect, how the 20–29 minute time rule works, and which real-world scenarios qualify.
What Is CPT Code 99213?
CPT code 99213 is used to report a Level 3 Evaluation and Management (E/M) office or outpatient visit for an established patient. This code applies when the visit involves low-complexity medical decision-making or when the provider spends 20–29 minutes of total time on the date of the encounter.
Maintained by the American Medical Association, CPT 99213 is part of the standardized coding system that ensures clear communication between healthcare providers and insurance payers. It is most commonly billed for routine follow-ups, chronic condition management, and uncomplicated acute issues.
Official 99213 CPT Code Description
According to the AMA, CPT 99213 describes an office or other outpatient visit for the evaluation and management of an established patient with a stable chronic illness or acute uncomplicated injury.
This level of service typically includes:
- A medically appropriate history and/or examination
- Low-level medical decision-making
- 20–29 minutes of total provider time (when time-based coding is used)
The clinical examples associated with this code are illustrative, not restrictive, and reflect common scenarios encountered in everyday medical practice.
Key Components of CPT Code 99213
To correctly report CPT code 99213, all required components must be supported by documentation. The code can be selected based on medical decision-making (MDM) or time, as outlined in the current E/M guidelines.
1. Established Patient Requirement
An established patient is one who has received professional services from the same provider or another provider of the same specialty within the same group practice within the last three years.
If the patient does not meet this definition, CPT code 99213 cannot be billed.
2. Medically Appropriate History and/or Examination
For CPT 99213, the history and exam should be relevant to the patient’s chief complaint and medically appropriate for the condition being evaluated.
This may include:
- A focused or expanded history of the present illness (HPI)
- A targeted review of systems (ROS)
- A problem-focused or expanded problem-focused physical exam
There are no rigid documentation bullet requirements, but the information recorded must support the medical necessity of the visit.
3. Low-Level Medical Decision-Making (MDM)
Low-complexity MDM is a defining feature of CPT 99213. This typically involves:
- One or two stable diagnoses
- Limited data review, such as basic lab results or imaging
- Low risk of complications, morbidity, or mortality
Common examples include managing stable chronic diseases, adjusting medications, or treating minor acute conditions that do not require extensive workup.
4. Time-Based Coding Option (20–29 Minutes)
Providers may choose to bill CPT 99213 based on total time spent on the date of the encounter rather than MDM.
The total time must fall between 20 and 29 minutes and may include:
- Reviewing medical records or test results
- Performing the evaluation and examination
- Counseling and educating the patient
- Ordering medications or tests
- Documenting the encounter
Staff time and separately billable procedures are excluded from the total time calculation.
Typical Patient Description for CPT Code 99213
CPT 99213 is most often used when an established patient presents with a condition that is stable, uncomplicated, and low risk.
Examples include:
- A patient with controlled hypertension attending a routine follow-up
- A diabetic patient undergoing regular monitoring
- A patient with a minor injury requiring evaluation but no extensive treatment
These visits do not involve high-risk decision-making or complex diagnostic processes, making them well-suited for a Level 3 E/M service.
Common Clinical Scenarios Where CPT Code 99213 Applies
CPT code 99213 is appropriate in a wide range of everyday clinical situations. Below are some commonly accepted scenarios that support its use.
Follow-Up Visit for a Fractured Arm
An established patient returns for a follow-up after initial fracture treatment. The provider assesses pain levels, mobility, swelling, and healing progress. Minor medication adjustments are made, and no advanced intervention is required.
Low complexity + established patient = CPT 99213
Routine Check-Up for a Diabetic Patient
A patient with controlled diabetes visits for routine monitoring. Blood glucose levels are reviewed, vitals are taken, and the current treatment plan is adjusted if needed. This encounter involves low-risk management of a stable chronic condition, making CPT 99213 appropriate.
Medication Side Effect Management
An established patient presents to discuss side effects from prescribed medications. After evaluation, the provider adjusts dosage and provides counseling. Because the decision-making is limited and the patient is stable, this visit qualifies for CPT 99213.
Documentation Requirements for CPT Code 99213
Accurate and complete documentation is essential to support CPT code 99213 and withstand payer reviews or audits. While E/M guidelines are more flexible than in the past, documentation must clearly justify medical necessity and the level of service billed.
Required Documentation Elements
To properly support CPT 99213, the medical record should include:
Chief Complaint (CC):
Clearly state the patient’s reason for the visit (e.g., follow-up for hypertension, medication side effects).
History of Present Illness (HPI):
Describe the patient’s current condition, including onset, duration, severity, and any changes since the last visit.
Review of Systems (ROS):
Document systems relevant to the chief complaint and overall health status.
Past, Family, and Social History (PFSH):
Include any relevant history that impacts the current visit or treatment plan.
Physical Examination:
Perform and document a problem-focused or expanded problem-focused exam related to the patient’s complaint.
Assessment and Plan:
Clearly outline diagnoses, treatment decisions, medications, patient education, and follow-up instructions.
Total Time (if applicable):
If billing based on time, document 20–29 minutes of total provider time spent on the date of service.
Medical Decision-Making (MDM) Breakdown for CPT 99213
Medical decision-making for CPT 99213 must fall under low complexity, which is determined using three factors:
1. Number and Complexity of Problems Addressed
- One or two stable chronic conditions
- One acute, uncomplicated illness or injury
2. Amount and Complexity of Data Reviewed
- Minimal data review
- Basic labs, imaging results, or prior notes
3. Risk of Complications and/or Morbidity
- Low risk from diagnostic testing or treatment
- Non-invasive management and routine medications
When two of these three elements meet low complexity, CPT 99213 is supported.
Who Can Bill CPT Code 99213?
CPT code 99213 may be reported by qualified healthcare professionals providing E/M services in an outpatient setting, including:
- Physicians (MDs and DOs)
- Nurse Practitioners (NPs)
- Physician Assistants (PAs)
Eligibility depends on state scope-of-practice laws and payer-specific policies. The service must still meet all documentation and medical necessity requirements.
CPT 99213 Modifiers: When to Use Them
Modifiers provide additional context about the circumstances under which the service was rendered. When used correctly, they can help prevent claim denials.
Common Modifiers Used With CPT 99213
Modifier 25: Used when a significant and separately identifiable E/M service is performed on the same day as another procedure.
Modifier 95: Indicates the service was provided via telehealth, when allowed by payer policy.
Modifiers should only be appended when fully supported by documentation.
CPT 99213 vs Other Established Patient E/M Codes
CPT 99212 vs 99213
- Lower time requirement
- Simpler decision-making
- Minimal documentation complexity
CPT 99213 vs 99214
- 99214 requires moderate complexity MDM
- Longer total time
- Higher patient risk and data review
Correct code selection ensures proper reimbursement and compliance.
Common Coding and Billing Mistakes to Avoid
Even experienced providers and billing teams can make errors when reporting CPT 99213. Common mistakes include:
- Upcoding: Billing 99213 when the visit supports a lower-level code
- Downcoding: Underbilling when documentation supports a higher level
- Incomplete documentation: Missing time, assessment, or plan details
- Incorrect modifier use: Applying modifiers without justification
- Outdated guidelines: Not following current E/M rules from the American Medical Association
Avoiding these mistakes protects your practice from audits and revenue loss.
Billing and Reimbursement Tips for CPT Code 99213
To improve reimbursement accuracy and reduce denials:
- Ensure diagnosis codes align with documented conditions
- Track and document time accurately
- Confirm payer-specific E/M policies
- Maintain clean, audit-ready records
- Train staff on updated E/M guidelines
Consistency and clarity are key to successful billing.
Final Thoughts
CPT code 99213 is ideal for routine established patient visits involving low-risk conditions and straightforward management. When documented correctly, it supports accurate reimbursement, minimizes compliance risk, and reflects the true level of care provided.
By understanding the time rules, MDM requirements, and documentation standards, providers and billing teams can confidently report CPT 99213 and avoid costly errors.
