If your providers bill 99213 for nearly every established patient, take a second look. Some of those notes support 99213. Some support 99214, and you’re being paid less than the work earned. A few don’t clearly support either, and those are the ones an auditor finds.
Here’s what 99213 requires, how to document it, and where practices usually get it wrong.
What is CPT code 99213?
99213 is an office or other outpatient visit for an established patient that needs a medically appropriate history and/or exam and a low level of medical decision making (MDM). If you pick the level by time instead, the provider needs at least 20 minutes of total time on the date of the visit.
It sits in the 99202 to 99215 office visit family. Since the AMA’s 2021 E/M changes, history and exam don’t set the level anymore. You still document them, but the level comes from MDM or total time, and you can use whichever one the note supports better.
Who counts as an established patient?
Someone who got a professional service in the last three years from the same physician or qualified health care professional, or from another physician of the exact same specialty and subspecialty in the same group. Anyone else is new and gets 99202 to 99205. It sounds basic. It still causes a steady stream of denials, usually when a provider joins from another group or a patient comes back after a long gap.
How to qualify for 99213 with medical decision making
MDM has three parts. Two of the three have to reach “low”:
| MDM element | What “low” looks like |
|---|---|
| Number and complexity of problems addressed | Two or more self-limited or minor problems; or one stable chronic illness; or one acute, uncomplicated illness or injury; or one stable acute illness |
| Amount and complexity of data reviewed and analyzed | Limited: at least two items from reviewing prior external notes (per unique source), reviewing each unique test result, or ordering each unique test; or an assessment that needs an independent historian |
| Risk of complications from patient management | Low risk from further testing or treatment, such as over-the-counter drugs or physical therapy |
The two-of-three rule trips people up. Prescription drug management is moderate risk, so providers assume a prescription pushes the visit to 99214. It doesn’t on its own. If the problem is low complexity and there’s little data, MDM is still low.
Example 1: stable chronic condition
An established patient comes in for a blood pressure check. It’s controlled, and the provider renews the same medication.
- Problems: one stable chronic illness (low)
- Data: nothing beyond the visit (minimal)
- Risk: prescription drug management (moderate)
Problems and risk both reach at least low. That’s 99213.
Example 2: acute uncomplicated illness
An established patient has symptoms of an uncomplicated UTI. The provider orders a urinalysis and prescribes an antibiotic.
- Problems: one acute, uncomplicated illness (low)
- Data: one test ordered (minimal, since “limited” needs two items)
- Risk: prescription drug management (moderate)
Same result. 99213.
How to qualify for 99213 with time
By time, the provider needs 20 minutes or more of total time on the date of service. Face-to-face and non-face-to-face work by the physician or other qualified health care professional both count:
- Preparing for the visit, including reviewing tests and records
- Getting or reviewing a separately obtained history
- The exam
- Counseling or educating the patient, family or caregiver
- Ordering medications, tests or procedures
- Referring to or talking with other clinicians (if not billed separately)
- Documenting in the record
- Independently interpreting results and communicating them (if not billed separately)
- Care coordination (if not billed separately)
Clinical staff time doesn’t count, and neither does travel or time spent on services you bill separately. Write the total and a few words on what it covered: “Total time on date of service: 24 minutes, including record review, counseling on medication adherence and documentation.” “Spent 20 minutes with patient” is much harder to defend.
99212 vs 99213 vs 99214 vs 99215
| CPT code | MDM level | Total time (must meet or exceed) |
|---|---|---|
| 99212 | Straightforward | 10 minutes |
| 99213 | Low | 20 minutes |
| 99214 | Moderate | 30 minutes |
| 99215 | High | 40 minutes |
Most arguments happen at the line between 99213 and 99214. A 99214 needs moderate in two of the three elements. Typical examples: a chronic illness that’s getting worse, plus prescription drug management. Or two or more stable chronic illnesses, plus prescription drug management. If only one element is moderate, you’re still at 99213.
Prolonged service codes aren’t an option here. CPT 99417 and Medicare’s G2212 only go with 99205 and 99215.
Documentation checklist for 99213
- Chief complaint and a medically appropriate history and exam
- Every problem addressed, with its status (stable, acute uncomplicated, and so on)
- Tests ordered or reviewed, and outside records reviewed, with the source named
- The plan: medications started, changed or renewed, therapy, referrals
- If billing by time, total minutes on the date of service and what they covered
- Provider signature and date, and the right rendering provider on the claim
Modifiers and add-on codes used with 99213
Modifier 25
Add modifier 25 when the provider performs a significant, separately identifiable E/M service on the same day as a minor procedure or another service. The note has to show work beyond the normal pre- and post-procedure evaluation. Some practices attach 25 to every visit that has a procedure. Auditors look for exactly that.
G2211 (Medicare)
G2211 is a Medicare add-on for visits that are part of an ongoing, longitudinal relationship. Think of a primary care practice that manages the patient’s overall health, or a specialist giving continuing care for a serious or complex condition. You can report it with 99213 when the visit qualifies. Since 2025, CMS also allows G2211 on a modifier 25 visit if the other same-day service is an annual wellness visit, vaccine administration or a Medicare Part B preventive service. Commercial payers set their own rules, so check before you add it to non-Medicare claims.
Telehealth
You can often bill 99213 for telehealth. The place of service code (POS 02 or 10) and modifier (such as 95) depend on the payer, and the rules have changed almost every year since 2020. Check current Medicare and commercial policies before you submit.
How much does 99213 pay?
It depends on the payer, your contract, your locality and whether the visit was in a facility or non-facility setting. For Medicare, use the CMS Physician Fee Schedule Look-Up Tool on the CMS website for your locality’s current rate. For commercial plans, check your fee schedule. Many contracts are built as a percentage of Medicare.
The per-visit amount matters less than the volume. 99213 is one of the most frequently billed codes in outpatient care, so a small, repeated error, like a missing modifier or a visit coded one level low, adds up quickly across a year of claims.
Common 99213 billing mistakes that cause denials
We’d put documentation first. A note that lists a diagnosis without its status or what the provider decided doesn’t show MDM, however clear it was to the provider in the room.
Undercoding comes next, and it’s the one practices rarely notice. Providers who aren’t sure pick 99213 to be safe. The visit met 99214, the claim goes through, and nobody ever sees the difference.
The rest are more mechanical:
- Billing by time without writing the total time and what it covered
- Using the established patient code for a new patient, or the other way round
- Leaving off modifier 25 when it’s needed (the E/M gets bundled), or adding it with no separate documentation
- ICD-10-CM codes that don’t match the problems the provider actually addressed
- Front-end errors in eligibility, coverage and demographics, which still cause plenty of rejected E/M claims
How IPClinical helps practices bill E/M visits correctly
Our certified coders read the note, choose the level it supports, add the right modifiers and add-on codes, and work every denial that comes back. If most of your visits are 99213 and 99214, start with a coding audit. It shows whether your levels match your documentation before a payer does. See our medical billing services and denial management services, or our billing support for family practice and internal medicine.
Request a free E/M coding audit and we’ll compare a sample of your visit levels against the notes behind them.
Frequently asked questions about CPT 99213
What is the time requirement for CPT 99213?
At least 20 minutes of total practitioner time on the date of the visit, if you’re choosing the level by time.
Can 99213 be billed for a new patient?
No. It’s for established patients only. New patients use 99202 to 99205.
What is the difference between 99213 and 99214?
99213 needs low MDM or 20 minutes. 99214 needs moderate MDM or 30 minutes. Moderate usually means a worsening chronic condition, several chronic conditions, or moderate-risk management together with another element at moderate.
Do history and exam still decide the 99213 level?
No. Since 2021 they only need to be medically appropriate. MDM or total time sets the level.
Can I bill G2211 with 99213?
For Medicare patients, yes, when the visit is part of an ongoing longitudinal care relationship as CMS defines it. Commercial payers vary.
Can 99213 be used with modifier 25?
Yes, when a significant, separately identifiable E/M service happens on the same day as a procedure or other service and the note supports it.
Sources: AMA CPT® Evaluation and Management (E/M) Services Guidelines; CMS Medicare Learning Network, Evaluation and Management Services Guide; CMS Physician Fee Schedule final rules. This is general billing guidance, not legal or payer-specific advice, so confirm current payer policies before you bill. CPT® is a registered trademark of the American Medical Association.
