99213 CPT Code – Updated Rules, Time and MDM Guidelines

February 25, 2026 Share on

CPT code 99213 is one of the most commonly used outpatient visit codes for established patients. It covers routine evaluation and management (E/M) services of moderate complexity, often visits of about 20–29 minutes or low‑complexity decision making.

This code is a workhorse in outpatient billing. According to Medicare data, 99213 makes up more than 25 % of all office‑based E/M claims submitted to Medicare each year and is consistently among the top five most billed CPT codes in the U.S. In family medicine clinics, codes at the level of 99213 or similar make up the majority of visits.

Correctly using 99213 helps practices receive fair payment, follow insurer and Medicare rules, and prevent denials or audits.

Mistakes in coding can delay payments, lower reimbursement, and increase administrative work. Understanding the documentation and use of this code is essential for accurately billing hundreds of millions of office visits nationwide and providing good patient care.

What Is CPT Code 99213?

99213 CPT Code Description

CPT 99213 is a medical billing code for established patients visiting a doctor’s office or outpatient clinic. It’s used when a doctor:

• Reviews your medical history
• Examines you
• Makes moderate-level medical decisions

Common reasons doctors use 99213

• Follow-up visits for chronic conditions like high blood pressure, diabetes, or asthma
• Treating minor illnesses like colds or sinus infections
• Adjusting medications
• Giving advice on healthy lifestyle changes or preventive care

What’s needed to bill 99213

Patient Eligibility

For a visit to be billed correctly, the patient must be established with the provider.

Visit Location

The visit can take place in an office, outpatient clinic, or via telehealth if allowed by regulations and payer rules.

99213 CPT Code Requirements

Proper documentation is essential for accurate billing. This should include:

• The patient’s current problem (History of Present Illness)
• Relevant symptoms and review of systems
• Physical exam findings
• Evidence of moderate-complexity medical decision-making
• A clear explanation of why the visit is medically necessary
• The doctor’s signature

Quick Billing Checklist

To ensure smooth billing and avoid claim issues, follow this checklist:

• Confirm the patient is established
• Verify the visit setting is correct (office, outpatient, or telehealth)
• Document history, symptoms, and physical exam
• Show moderate-complexity medical decision-making
• Explain medical necessity
• Include the doctor’s signature

CPT Code 99213 Time Range Guidelines

CPT code 99213 represents an established office or outpatient evaluation and management (E/M) service, typically billed for an established patient encounter.

According to current guidelines

The total time spent on the date of the encounter ranges from 15 to 29 minutes.

This total time includes all provider activities related to patient care, both face-to-face and non-face-to-face, performed on the same day.

What Counts Toward Total Time

When calculating for CPT Code 99213 time spent, both face-to-face and non-face-to-face activities directly related to patient care are included.

Face-to-Face Activities

• Taking the patient’s history
• Performing a physical examination
• Counseling the patient
• Providing patient education

Non-Face-to-Face Activities

• Reviewing laboratory or imaging results
• Communicating with other healthcare professionals regarding patient care
• Documentation in the medical record
• Ordering medications or tests

99213 CPT Code Time Spent Documentation Best Practices

Accurate documentation of time is critical for compliance and reimbursement. Best practices include:

• Record start and end times of all activities related to patient care.
• Detail both face-to-face and non-face-to-face tasks performed.
• Specify the purpose of each activity in the medical record.
• Ensure that documentation supports the total time claimed, particularly if billing is based on time rather than MDM.

Medical Decision Making (MDM) Rules for 99213

Medical Decision Making (MDM) is how doctors figure out a patient’s diagnosis, review tests and information, and decide on the best treatment. It’s a key part of billing for evaluation and management (E/M) visits. For CPT 99213, MDM can be used instead of tracking exact time.

MDM Level for 99213

Low complexity: This means the doctor deals with a small number of problems, looks at a moderate amount of information, and the risk of complications is low.

Main Parts of MDM

Problems Addressed

• Usually 1–2 minor issues, or one chronic issue that’s a little worse than usual.
• Must be written clearly in the medical record.

Data Reviewed

• Includes labs, tests, scans, and previous visit notes.
• Sometimes doctors order new tests or check outside records.

Risk of Complications

• Look at how risky the treatment or tests are.
• For 99213, risk is low, like minor medication changes or advice on lifestyle habits.

Diagnosis Codes for CPT Code 99213

Using the right ICD-10 diagnosis code 99213 is important to show that medical services are needed and to get correct payment for CPT 99213. The codes should match the patient’s symptoms, exam results, and treatment plan. Insurance companies often check these codes along with visit notes to make sure the service is justified.

Common Diagnoses Billed with 99213

• High blood pressure (I10)
• Type 2 diabetes (E11.x)
• High cholesterol (E78.5)
• Upper respiratory infections (J06.9)
• Back or other musculoskeletal pain (M54.5)

Why Linking Diagnosis Matters

Each diagnosis should connect clearly to the patient’s symptoms and care plan. Proper documentation helps prevent claim denials and ensures CPT 99213 is billed correctly.

99213 CPT Code Reimbursement and Payment Rates

CPT 99213 is used for visits with patients you’ve seen before, usually when the doctor makes a low to moderate level of medical decisions or spends about 20–29 minutes face-to-face with the patient. Knowing how much you’ll be reimbursed is important for managing billing and revenue.

Typical Reimbursement

Medicare: Around $75–$100 per visit

Commercial insurance: Usually $100–$200, depending on the plan

Medicare vs. Commercial Insurance

Medicare payments are mostly the same nationwide, with small regional differences.

Commercial insurance can pay more, but the amount varies by contract. Always check the payer’s fee schedule before submitting a claim.

What Can Affect Payment

Payments for services can be different depending on where you are, because insurance rules and local rates vary by region. A clinic’s or provider’s agreements with insurance companies directly affect how much they are paid. Using the correct billing codes and modifiers is also vital, because wrong codes can lead to denied claims or reduced payments.

Common Billing Mistakes

• Missing time or decision documentation: Claims can be denied if the doctor’s notes don’t show how long the visit took or the level of medical decision-making.

• Upcoding or downcoding: Charging for a higher-level visit than documented can trigger audits; charging too low can lose revenue.

• No proof of medical necessity: Insurers need to see why the visit was necessary.

• Incorrect modifiers: Wrong use of modifiers like 25 or 59 can delay or reject payment

Best Practices for Accurate 99213 Billing

Reduce Errors with Consistent Policies and Training

• Use Standardized Documentation Templates

Templates make sure every visit includes all the important details, like the patient’s main complaint, medical history, exam findings, and medical decision-making (MDM). This consistency helps prevent missing information.

• Train Providers on Time and MDM Rules

Regular training keeps providers up-to-date on CPT coding rules. This helps them choose the right code and support their services with proper documentation.

• Conduct Internal Audits and Compliance Checks

Routine reviews catch mistakes early and reduce the risk of non-compliance. Proactively checking documentation and billing processes increases the chances that claims are approved on the first submission.

Closing Words

Accurate use of medical procedure code 99213 is key to getting proper reimbursement, staying compliant, and keeping your practice’s billing efficient. By understanding the latest rules, following time and medical decision-making (MDM) guidelines, and maintaining consistent documentation, practices can reduce claim denials and ensure timely payments.

For expert guidance on 99213 billing, documentation, and compliance strategies, contact HMS Group Inc to optimize your revenue cycle and smooth workflow.

Frequently Asked Questions About Procedure Code 99213