Each five-digit CPT code in medical billing and coding has more value and significance than you might realize. These codes are the mechanism through which healthcare providers articulate the value of their clinical services to their payers. Their specificity and accuracy of use determine if a claim gets reimbursed in a timely fashion or results in another unpaid item on the ledger.
Among thousands of CPT codes defining today’s healthcare, CPT code 99213 is one of the most utilized. In the following, let’s break down CPT 99213 together, so that every minute of care you provide gets converted into efficient and accurate reimbursement.
Description of CPT Code 99213
CPT Code 99213 defines a Level 3 office or outpatient visit for an established patient. According to the American Medical Association (AMA), procedure code 99213 is used when a healthcare provider, for example, a primary care physician, orthopedist, or clinical psychologist, spends 20 to 29 minutes on the date of the encounter, or the visit involves low-complexity medical decision-making (MDM).
Concepts to Understand Before Using CPT 99213
Evaluation and Management (E/M) Visits
E/M codes capture cognitive services provided by either a physician or a qualified healthcare practitioner. CPT code 99213 specifically captures established patients with low complexity Medical Decision Making (MDM) or 20-29 minutes of total time. Each element, history, exam, and MDM, must correspond to the visit type and complexity.
Low-Complexity Medical Decision Making
Low-complexity MDM is appropriate for conditions involving limited information or data review, minimal risk, and simple clinical decision making. Examples would include the management of stable chronic disease (hypertension, diabetes) or an acute, uncomplicated issue.
For CPT 99213:
- Problems: One or more stable chronic illnesses or an acute, uncomplicated problem.
- Data: Limited data review (labs, notes, or imaging)
- Risk: Low level of complication or morbidity
Established Patients in an Outpatient Setting
The 99213 procedure code applies only to established patients, those who have been seen by the same provider or group (same specialty) within the past three years. It cannot be billed for new patients. Encounters usually take place in an office or outpatient clinic, but can also apply to telehealth visits when billed with Modifier 95 and the appropriate place of service (POS 02 or 10).
Scenarios Where CPT Code 99213 Is Applicable
These are some common types you may encounter in practice:
1. Follow-up of a Chronic Condition that is Controlled
A patient with hypertension returns for a follow-up for their blood pressure. The provider reviews the patient’s blood pressure logs. The provider then performs a focused exam and makes medication changes as appropriate. Overall, this encounter is of low complexity and may be billed using CPT 99213.
2. Routine Diabetes Follow-up or Check-in
A patient with type 2 diabetes has a quarterly follow-up or check-in. The provider reviews the patient’s HbA1C, discusses diet, and reviews medication compliance. Since the patient’s diabetes is stable and the medication changes were small, this visit can be billed with CPT 99213.
3. Follow-Up of New Side Effects from Medication
A patient returns stating they have had new side effects from the antidepressants that they are taking. The provider performs a focused history and appropriate exam, makes small discussions about medication choice, and possibly a dosage change. This is both a simple evaluation and treatment plan (prescribing medication). This is an easy case to utilize CPT 99213.
4. Mild or Minor Acute Illness Visit
A patient presents to the clinic with a sore throat and low-grade fever. The provider performs an exam, potentially does a rapid strep test, and provides a low complexity treatment plan. The overall MDM is low complexity and a routine visit. Overall, this is a CPT 99213 visit.
5. Follow-Up Appointment for Injury
A patient with a healing fracture attends the follow-up appointment. The provider reviews the X-rays, assesses the patient’s mobility, and provides home exercise recommendations. Because the patient is making predictable progress, this use case supports 99213.
6. Follow-Up Appointment for Mental Health Status
A patient with anxiety or any other mental health disorder presents for a medication management appointment. The provider checks in on the patient’s symptoms and makes slight adjustments to the medication dosage. As the condition remains stable, this follows the use case for code 99213.
Reimbursement Criteria for CPT Code 99213
To receive appropriate reimbursement for CPT 99213, you must comply with the documentation and coding guidelines set forth by the AMA and CMS.
- Complexity: The visit must be of low-level medical decision-making (MDM). Billing CPT 99213 for moderate or high complexity can result in an increase in the chances of over- or under-coding.
- Documentation: The notes must include a detailed history that is focused on the exam, and a low-complexity MDM that supports the need for the visit.
- Time: When billing based on the data of overall time spent on the date of service, include documentation of 20-29 minutes of the total time of the visit.
- Place of Service (POS): POS 02 or POS 10 with Modifier 95 are used for telehealth visits.
- Exclusive Billing Rule: CPT 99213 cannot be billed with another E/M code on the same day for the same patient. Only the higher-level service would be payable.
- Medical Necessity: The visit must be reasonable and necessary with documentation supporting the provider’s evaluation and management.
Common CPT 99213 Billing Errors Leading to Denied Claims
Maintaining strong Evaluation and Management documentation protects the provider during CMS audits and ensures timely payment. While CPT 99213 is frequently utilized, it is also frequently denied due to user errors. The common errors include the following:
- Partial documentation: Missing details in the patient’s history, exam, or MDM.
- Incorrect E/M level: The complexity of this visit does not match the low-level MDM criteria of 99213.
- Incorrect use of modifier: Modifier 25 was not used when another procedure or a service is billed on the same day.
- Insufficient patient information: Lack of documentation for medication changes, diagnostic results, or care plans.
- Incorrect use of pos or telehealth coding: Use of an incorrect Place of Service or a missed required modifier will be reported for within the denial or for reduced payment.
Billing Guidelines for CPT Code 99213
When billing CPT 99213, regular internal audits and coder education on E/M documentation standards help keep compliance strong across all outpatient code 99213 encounters.
Take note of the points below to ensure fewer denials:
Patient Must Be Established
CPT 99213 is reserved for established patients being seen for the first time by you or your group in the past three years.
Level of Medical Decision-Making
Use 99213 when you have low-complexity MDM, usually seen with a stable chronic condition or uncomplicated acute problems. Use 99214 when the MDM requires complexity.
Proper Documentation
You must include all required elements in your notes about the patient’s condition, notes from your physical examination, the treatment plan, and any rationale for your decisions. Clear and concise notes can assist with appropriate billing and potential compliance concerns.
Time-Based Billing
When billing by time, you need to clearly document that the time was 20-29 minutes and what was done during the time, such as discussing tests or educating the patient.
Avoiding Coding Errors
Make sure that the E/M code you use is based on either the medical decision-making or time, so your practice does not lose revenue from under-coding or exposing your practice to being audited based on over-coding.
Payer and Compliance Rules
It is important to check for E/M documentation policies for each of your payors that can then be updated annually for the CMS.
Correct Usage of Modifiers 25 and 95
Modifier 25 identifies that an E/M service, like procedure code 99213, was performed on the same day as another service but was significant and separately identifiable.
Modifier 95 indicates a synchronous telehealth E/M encounter, allowing providers to bill office visits delivered virtually.
The Takeaway
While being one of the most E/M codes used, CPT code 99213 is prone to several misrepresentations. To master this code, it is imperative to maintain clear documentation of history, examination, and low-complexity decision-making. Ensuring strict adherence to payer and CMS standards is also another step you can take to minimize the denials for the CPT code.
Many providers rely on professional billing partners like Nexus IO to provide medical billing services, ensuring each claim is fully documented, accurately coded according to CPT code 99213 billing guidelines, and processed without errors, leading to timely reimbursement and compliance peace of mind.
FAQs
What Is Low Complex MDM In CPT 99213?
CPT code 99213 involves making low-complexity medical decision making that groups a limited number of problems. It also involves gathering minimal data and taking care of low-risk issues.
What Is the Difference Between CPT 99213 and CPT 99214?
The basic difference between CPT 99213 and CPT 99214 relates to the time and complexity level of the services provided to the patient.
CPT 99213 implies low-complexity MDM (20-29 minutes) while CPT 99214 refers to moderate-complexity MDM (30-39 minutes).
Is There a Specific Diagnosis Code for CPT 99213?
There is not a single diagnosis code (ICD-10-CM) associated with procedure code 99213. Rather, the diagnosis should represent the condition evaluated or managed at the visit accurately.
May a Nurse Practitioner or Physician Assistant Bill CPT 99213?
Yes. Qualified healthcare providers (QHPs) such as nurse practitioners (NPs) or physician assistants (PAs) may bill CPT 99213 if their documentation conforms to the same requirements as the Evaluation and Management (E/M) guidelines for physicians. The supervising physician’s NPI and the payers’ rules for shared or split visits must be followed.
How Does Time-Based Coding Work for CPT 99213?
For CPT 99213, its time-based coding applies if the provider spends 20–29 minutes on the date of service in satisfying all associated care, i.e., in both face-to-face and non-face-to-face activities within the visit.
