CPT Code 99213: Established patient office visit, 20-29 minutes

Learn more about the documentation requirements and guidelines for using CPT code 99213: Established patient office visit, 20-29 minutes.

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What is CPT code 99213?

CPT code 99213 is one of the CPT codes maintained by the American Medical Association (AMA), used in the healthcare industry, that refers to an office or other outpatient visit that involves evaluation and management services. It can represent a level 3 outpatient office visit.

According to the AMA, 99213's code description is "Established patient office visit, 20-29 minutes," and it typically applies to established patients whose visit may:

include low-level medical decision-making
require an appropriate medical history and/or examination

This code is commonly used by healthcare providers in their medical practice, specifically during scenarios such as follow-up visits, routine check-ups, etc.

CPT code 99213 documentation requirements

Here are all the requirements healthcare professionals need to keep in mind for consistent and accurate documentation and coding:

Expanded-problem focused history: For proper documentation of the patient's medical history, the patient's chief complaint, extended history of present illness (HPI), and pertinent review of systems (ROS) must be present.
Expanded problem-focused examination: In this component, the results of tests for vital signs and measurements, as well as observations for any impairments or limitations, must be written down.
Medical decision making (MDM): For this section, the healthcare provider must mention and/or elaborate on the diagnosis and treatment plan, including any risks the patient may have.
Time-based reporting: If billing is based on time, documentation must reflect that 20-29 minutes were spent on patient care by describing what was done during that time.

CPT code 99213 billing code guidelines

After a healthcare provider conducts accurate and thorough documentation, they may bill their medical services. For ease of the billing process, here are the guidelines one can follow:

Used for established patients seen in an outpatient setting.
Documentation must justify medical necessity and the level of service provided.
Ensure compliance with payer-specific rules, as some insurers require specific documentation elements.

Other relevant CPT codes

99212: Visits with straightforward MDM (10-19 min).
99214: Visits with moderate MDM (30-39 min).

Frequently asked questions

The main differences between the two codes are the nature and complexity of medical decision making and the time spent with the patient. 99214 is for more complex visits that may require the healthcare provider to spend time with the patient for around 30 to 39 minutes.

Rates will vary depending on the insurance company, location, etc. However, rates can range from around $87 to over $250.

One example could be a follow-up with a patient with hypertension but who has controlled blood pressure, wherein the healthcare provider will check their condition, adjust their medication (if needed), and provide recommendations for any further lifestyle modifications (if needed).