For those providing care to patients, the quality of care is most important to the hospital or clinic. For the business side of the practice though, the most important thing is the care is documented, care is provided, and is getting paid to practice on a continuous and timely basis. The five-digit numbers that attribute to the nurses visit on a patient account are what keep the business overhead in the green. Some of these numbers are as influential and everywhere as CPT code 99213.
At A2Z Billings, we understand that the importance of administratively mastered coding is not administration. Rather, it is financially staying afloat and being compensated for the work you do.
What is CPT Code 99213? The Backbone of the Established Patient Visit
CPT Code 99213 is considered one “Office or other outpatient visit for the evaluation and management of an established patient”. This translates to a patient follow-up from your office/patient. The office should have seen the patient within the past 3 years.
The CPT code 99213 describes the visit involving a low level of medical decision-making (MDM). For this code to qualify for use by the provider, he or she must have completed a medically appropriate history and/or physical examination. As of 2021, code selection may be determined by the complexity of the MDM or by the total time spent on the patient for the day of the encounter. For 99213, 20 minutes must be met or exceeded in order to use the code.
Real-World Scenarios for 99213
What does this encompass in real life? It includes a lot of frequent follow-up questions:
- Regular checkup for a patient with calm, controlled high blood pressure/diabetes.
- Check-ups after a common acute illness such as a mild sprain or respiratory virus.
- Talking about and managing small, mild symptoms from a certain medication.
- Reviewing lab test results and creating a treatment plan with patients.
These appointments comprise the majority of primary and specialty care, so it isn’t surprising these codes, 99213 and 99214, made up an outstanding 92% of all established patient visits to family physicians in one CMS study.
The Critical Distinction: 99213 vs. 99214
Figuring out when to use 99213 or one of its sibling codes, 99214, is one of the more impactful decisions to be made in outpatient coding. This is an out-of-pocket expense and the expense is more than anything else, this is the primary difference. It is about 35 dollars per each visit difference between one code and the other, and for, say, a practice, that’s 250 visits. This is 9900 dollars revenue.
But what is the difference between a level 3 (99213) and level 4 (99214) visit? This is mainly the difference in the Medical Decision Making (MDM) complexity.
The following table breaks down the key differences:
| Feature | CPT 99213 (Level 3) | CPT 99214 (Level 4) |
| Medical Decision Making | Low Complexity | Moderate Complexity |
| Total Time (Time-Based) | 20-29 minutes | 30-39 minutes |
| Typical Problems | 1-2 stable chronic conditions or 1 new, simple problem | Multiple chronic conditions, a new problem with uncertain prognosis, or an acute complicated injury |
| Data Reviewed | Minimal or none (e.g., reviewing a single normal lab) | Moderate (e.g., reviewing multiple lab results, imaging studies, or consultant notes) |
| Risk | Low risk of morbidity | Moderate risk of morbidity; may involve prescription drug management |
Documentation is Key: Making the Case for 99214
What makes the higher level code able to be used is documentation. For example, a diabetic patient that presents and is only checking a stable A1C is a 99213, while if that same patient presents and has worsening symptoms, the provider increases the medication dosage, orders new labs, and spends a lot of time counseling the patient about diet, then that is 99214.
A good documentation framework for 99214 suggested by the AAFP is, a detailed history is simply, “4, 2, 1”: 4 elements of the History of Present Illness, 2 Review of Systems, and 1 Past, Family, or Social History.
Understanding and Applying Modifier 25 with 99213
When it comes to medical billing, another important aspect is applying the correct modifiers to the billed services. One modifier that is often misunderstood and is very important is modifier 25.
Modifier 25 is defined as “A Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service.”
To put it in very simple terms, if during the same patient visit, you have a billable office visit (like a 99213), and you perform a procedure (like a wound repair, injection, or lesion removal), that is billed as CPT code 99213 with modifier 25.
The Golden Rule for Modifier 25: Separate and Identifiable
The key thing to remember is that the E/M must be separate from the procedure. Take, for example the following:
- Correct Use: Yes, the patient was scheduled for a procedure to remove a lesion. During the visit, the patient comments that he has new, concerning chest pain. You perform an evaluation, order an EKG, and a plan is drafted. This chest pain evaluation is separate from the lesion removal which can be billed as 99213-25.
- Incorrect Use: The scheduled visit was for a lesion removal, which the patient has also been scheduled for. The pre procedure history and exam is exam and history solely focused on procedure. Hence, an E/M code with modifier 25 is not appropriate in this case.
To the documentation, there must be a sufficient explanation for the E/M service to be separate and to explain the necessity. The separate diagnoses must be clearly noted, and the distinct work must be explained for each component to the visit versus the component to the procedure. The auditing we do at A2Z Billings shows that strengthening documentation on modifier 25 is an easy method to lower claim denials and ensure claim payment.
Navigating Medicare and Other Payer Reimbursements
Reimbursement for CPT code 99213 is not a fixed number; it varies significantly based on the payer, your geographic location, and your practice’s contracted rates .
Medicare Reimbursement for CPT Code 99213
Medicare gets its pricing from something called the Physician Fee Schedule. This takes into account things like costs of expenses and work done by the physician as well as malpractice insurance. With respect to the CPT code 99213, the Medicare amount reimbursed changes by the location of the MAC (Medicare Administrative Contractor). Forecasts for 2025 shows these figures at $63 to $110 for the average. In 2025, the average Medicare allowed amount for 99214 is $124. This is to show how Medicare is different with 99214 code.
Commercial Payer Reimbursement
Private insurers like UnitedHealthcare or Blue Cross Blue Shield negotiate rates directly with providers and health systems. This leads to a wide range of CPT code 99213 reimbursement. Data from payer transparency files shows that contracted rates for the same service can vary dramatically, sometimes by hundreds of percent, even within the same city and specialty .
A Chart Check: Real-World Financial Impact
Let’s look at a common scenario from our client files at A2Z Billings. A busy internist sees 20 established patients a day. If 5 of those visits are legitimately 99214 but are consistently coded as 99213, the practice is losing:
Over a year, that’s $42,000 – revenue that could fund a new staff member, essential equipment, or practice improvements. This stark math is why we emphasize coding accuracy as a direct driver of practice health.
Best Practices for Accuracy and Compliance from A2Z Billings
Based on our experience helping hundreds of providers optimize their revenue cycles, here are our top recommendations:
- Educate Your Clinical Team: Coders can only code what is documented. Ensure providers understand the MDM elements and documentation requirements that differentiate 99213 from 99214. A brief, focused training can yield immediate results.
- Use Time as a Guide: If you spend more than 30 minutes total on a patient’s care (including documentation), strongly consider whether the visit meets 99214 criteria, either by time or complexity .
- Audit Regularly: Conduct periodic internal audits of your E/M coding distribution. Compare your percentage of 99213s vs. 99214s to national benchmarks. Are you under-coding? Our analytics often reveal patterns that, once corrected, lead to more consistent and appropriate reimbursements .
- Leverage Technology and Expertise: Consider partnering with a billing service that uses certified coders (CPC, CPB) who are experts in the latest ICD-10, CPT, and HCPCS standards . Advanced analytics dashboards can give you real-time visibility into denial trends, payer performance, and coder accuracy .
Conclusion
Getting a handle on CPT code 99213 and really making it part of your routine isn\’t merely a mindless bureaucratic task. It is essential to making your practice viable and able to continue to function. By concentrating on documentation of medical decision-making, to knowing the line to cross to 99214, to knowing when to use modifier 25, and by keeping on to the Medicare reimbursement rates, you can be sure your practice gets paid appropriately and on time for essential work.
Medical billing is complicated and can shift on a dime. At A2Z Billings, we think when we are able to relieve the provider of the burden of complicated coding, they can really concentrate on what they need to be focusing their attention on, their patients. If the scope of your practice is being held back by a complicated coding system, we are set up to assist you, A to Z, on optimizing your coding system to smooth out your revenue cycle, lessen claim denials, and give you peace of mind.
FAQs
- What does CPT Code 99213 mean and how is it used?
99213 is used for already existing patients. For CPT 99213 billing purposes, it is used for follow-up appointments, routine check-up, or management of chronic illness including enduring and stable conditions. 99213 is used for office or outpatient visit. 99213 is used when a physician’s decision-making is low and of minimal complexity. 99213 is used when there’s a low complexity of MDM and is engaged for a period of 20 to 29 minutes and there is low MDM of medical decision-making.
- What’s the difference between CPT 99213 and CPT 99214?
For 99214, the medical decision complexity is moderate. Other difference is the time difference where 99214 takes 30-39 minutes while for 99213 takes 20-29 minutes. For 992 companies to follow through is unsubstantively to become crucial as documentation for accuracy is essential for the purpose of coding of utmost accuracy.
- Would modifier 25 be applicable to CPT 99213?
99213 can have the modifier 25. Modifier 25 is used when there is a substantial and separately identifiable service for an E/M that takes place on the same date clinically for a procedure. 99213 can be appended on a Lesion Removal and for the evaluation of a new problem in medicine.
- What is the reimbursement for CPT Code 99213 on an average?
Generally reimbursement solely depends on a specific contract with the company and the geographic location. Adjust rates are made once Medicare analyzes 99213 CPT as between $63 to $110 and other insurances may provide a different diagnosis more than that. With the correct coding of CPT 99213, you go through the maximum revenue cycle.
- What can I do to not make the same mistakes when billing CPT 99213?
Take the time to document everything, be sure to differentiate what 99213 is from 99214 based on time or MDM, use modifier 25 appropriately, and do coding audits regularly. Working with a certified billing service can minimize claim denials and maximize revenue.