CPT Code 99213: Established Patient Office Visit, 20-29 minutes

CPT code 99213 reports an office or outpatient visit for an established patient involving low medical decision-making. It falls within the evaluation and management (E/M) category and ranks among the most frequently billed codes in outpatient medicine — second only to 99214 by total Medicare volume. 

Providers select 99213 through either low MDM (where two of three elements meet the low threshold) or 20-29 minutes of qualifying physician time on the date of service.

Accurate 99213 billing matters more than most practices realize. CMS identified roughly $98 million in 99213 improper payments during its FY2024 analysis — and the most frequent mistake is not undercoding. 

It is upcoding to 99214 based on a single moderate element that does not actually change the overall MDM level.

What does CPT code 99213 cover?

Every fact a billing team references regularly, captured in one table.

Detail	CPT 99213
Description	Established patient office visit, 20-29 minutes
Category	Evaluation and Management (E/M)
Patient type	Established only
MDM level	Low
Time	20-29 total physician/QHP minutes
Common modifiers	25, 95, 93
Medicare rate	~$95.19 non-facility / ~$57.45 facility (2026)
Commonly compared with	CPT 99214

The AMA describes a typical 99213 encounter as care for an established patient with a stable chronic illness or an acute uncomplicated illness or injury. Most 99213 visits involve routine follow-ups, medication monitoring, and straightforward acute problems that do not require complex workup.

When should you use CPT 99213?

Selecting between 99212, 99213, and 99214 depends on the actual clinical work performed — not what the schedule says or what modifier seems convenient.

Use CPT 99213 when

• The patient is established (seen within the past 3 years by the same provider or group specialty)
• At least two of the three MDM elements meet the low level
• Or the provider spends 20-29 qualifying minutes on the date of service
• The visit involves stable chronic disease monitoring, uncomplicated acute illness, or minor problem evaluation without moderate-level complexity

Consider an established patient returning for controlled hypertension. 

The physician evaluates blood-pressure control, reviews medication adherence, and continues the existing antihypertensive prescription. 

One stable chronic illness is a low problem element, data review is minimal, and prescription management — while technically moderate risk — is the only element that reaches moderate. With just one moderate element, overall MDM remains low, and 99213 is the right code.

When not to use it

• Two or more MDM elements reach moderate — use 99214
• The patient is new under CPT’s three-year rule — use 99203 for low-MDM new patients
• Total qualifying time hits 30+ minutes and the provider elects time-based coding — use 99214
• The E/M work is bundled into a same-day minor procedure without separately identifiable service
• The visit only addresses a self-limited problem taking under 20 minutes with minimal MDM — 99212 may apply

How is CPT 99213 selected?

Two independent pathways support 99213. A provider does not need both.

MDM pathway

At least two of these three elements must meet the low level per the AMA MDM grid.

MDM element	Low threshold for 99213
Problems addressed	2+ self-limited or minor problems, or 1 stable chronic illness, or 1 acute uncomplicated illness/injury
Data reviewed	Category 1 — any combination of 2 (review of unique external notes, review of unique test results, ordering unique tests) or Category 2 — assessment requiring an independent historian
Risk	Low risk of morbidity from additional diagnostic testing or treatment

A critical judgment call separates 99213 from 99214 here. 

Prescription drug management is an AMA example of moderate risk — but moderate risk alone is only one element. If the problems and data remain low, overall MDM stays low and 99213 applies. 

Practices that automatically upcode every prescription-management visit to 99214 are billing on a single moderate element, which does not meet the two-of-three requirement.

Time pathway

If 20-29 total physician/QHP minutes are spent on the date of service, 99213 is independently supported. 

Qualifying time includes chart review, history gathering, examination, counseling, ordering, coordination, and documentation. Time assigned to separately billed procedures or psychotherapy does not count.

When MDM determines the code, there is no CPT requirement to document time or to spend 20 minutes. Time documentation is only required when time is the basis for code selection.

What documentation supports CPT 99213?

For an MDM-selected 99213, the note must demonstrate that the conditions counted toward MDM were genuinely addressed — not just carried forward from a previous encounter.

The documentation should show

• Which conditions the provider actually evaluated or managed during the visit
• Clinical status of relevant conditions (stable, improving, worsening)
• Assessment, management plan, and treatment decisions
• Data reviewed or ordered, if data is counted toward MDM
• Medical necessity for the service

When billing by time, record the actual total minutes (e.g., “Total physician time today — 24 minutes”). If MDM supports 99213 independently, CPT does not require time documentation or a 20-minute visit.

The old “bullet counting” system for history and examination no longer determines the E/M level. 

Since the 2021 E/M changes, code selection depends on MDM or time — history and exam should be medically appropriate, not structured around documentation checkboxes.

How much does CPT 99213 reimburse?

Payment varies by setting, geography, and payer.

Payment type	2026 rate
Medicare non-facility (national baseline)	~$95.19
Medicare facility (national baseline)	~$57.45
Commercial payers (median observed)	~$92.75
Medicaid	Varies by state

Medicare rates from CMS 2026 PFS national baselines (non-QP conversion factor ~$33.40). Commercial median from Transparency-in-Coverage data (Reddenda, 2026).

The $38 gap between non-facility and facility rates exists because hospital outpatient departments separately bill for overhead — the professional fee covers only the physician’s work and a smaller practice-expense component.

One development worth flagging — CMS’s proposed 2027 rule includes a potential 50% payment reduction for same-day E/M services billed alongside procedures with global periods. 

If finalized, practices relying heavily on 99213-25 with minor procedures would see meaningful revenue impact.

Which modifiers apply to CPT 99213?

Only modifiers genuinely relevant to 99213 encounters.

Modifier	When it applies
25	Significant, separately identifiable E/M on the same day as a procedure — the E/M work must go beyond what is bundled into the procedure
95	Synchronous audio-video telehealth (Medicare and most commercial payers)
93	Audio-only telehealth (Medicare behavioral health and qualifying services through 12/31/2027)
24	Unrelated E/M during a postoperative global period

For Medicare telehealth, pair modifier 95 (audio-video) or 93 (audio-only) with POS 10 when the patient is home (non-facility rate) or POS 02 at another location (facility rate). 

The POS determines payment — POS 10 pays ~$95.19 while POS 02 pays ~$57.45. Commercial payer modifier and POS requirements vary by plan.

Modifier 25 remains the highest-risk modifier in E/M billing. OIG audits across ophthalmology and podiatry found noncompliance rates as high as 90% in sampled same-day E/M claims. 

Append 25 only when the E/M genuinely represents separate clinical work.

CPT 99213 vs. 99214 — which one fits?

The 99213-vs-99214 decision is the most debated E/M coding question in outpatient medicine. Both codes cover established patients — the entire difference rests on whether the clinical work reaches moderate complexity.

Feature	CPT 99213	CPT 99214
Patient type	Established	Established
MDM level	Low	Moderate
Time	20-29 minutes	30-39 minutes
Typical use	1 stable chronic condition, uncomplicated acute problem, 2+ minor issues	2+ stable chronic conditions, chronic exacerbation, acute illness with systemic symptoms
Medicare rate (2026)	~$95.19	~$135.61
Work RVU	1.30	1.92

Choose 99213 when overall MDM is low (fewer than two elements reach moderate) and qualifying time falls between 20-29 minutes.

Choose 99214 when at least two MDM elements reach moderate, or qualifying time reaches 30+ minutes.

The trap that catches the most practices — one stable chronic illness plus prescription management. 

Prescription management satisfies moderate risk, but one stable chronic illness is only a low problem. With just one moderate element, overall MDM stays low and 99213 applies. 

Add a second chronic condition being actively managed (like stable diabetes alongside hypertension), and the problems element jumps to moderate — now two elements qualify, and 99214 is correct.

What billing errors should you avoid with CPT 99213?

Five mistakes account for the majority of 99213 claim issues and audit exposure.

1. Upcoding to 99214 on a single moderate element 

Prescription drug management alone satisfies moderate risk — one element. Without a second moderate element in problems or data, the overall MDM is low and 99213 is correct.

2. Billing 99213 for a new patient 

99213 applies only to established patients (seen within three years by the same provider or group specialty). New patients with low MDM should be reported under 99203.

3. Counting problems that were not addressed 

Diagnoses on the problem list only count toward MDM when the provider actually evaluates or manages them during the encounter. Copy-pasted problem lists inflate MDM and create audit risk.

4. Double-counting time from separately billed services 

Psychotherapy time billed under 90833/90836/90838 cannot also count toward E/M total time. The same applies to procedure time. Each minute can only support one code.

5. Automatically attaching modifier 25 with same-day procedures 

Routine pre/post-procedure work is bundled. OIG audits have found noncompliance rates between 40-90% in modifier-25 claims. Append 25 only for genuinely separate E/M work documented independently from the procedure.

Frequently asked questions about CPT 99213

Here are some commonly asked questions about CPT 99213: