CPT 99213 is an office or outpatient visit for an established patient that requires low medical decision making (MDM), or at least 20 minutes of total time on the date of the encounter. It’s one of the most-billed codes in outpatient medicine, so it’s also one payers look at closely when the mix of 99213 and 99214 looks off.
What Does CPT 99213 Require?
Since the 2021 office E/M changes, you pick the level using either MDM or total time, not history and exam. A 99213 needs:
- An established patient, meaning one seen by the same physician or same-specialty physician in the group within the past three years.
- A medically appropriate history and/or exam. These still get documented, but they no longer set the level.
- Low MDM, or at least 20 minutes of total time on the date of service. CGS Medicare’s E/M fact sheet lists 99213 time as 20-29 minutes.
How Is Low Medical Decision Making Defined?
MDM has three elements, and two of the three must meet the level:
- Problems addressed: for low, examples include two or more self-limited or minor problems, one stable chronic illness, or one acute uncomplicated illness or injury.
- Data reviewed and analyzed: limited. Either any two of reviewing prior external notes, reviewing test results, or ordering tests, or an assessment that needs an independent historian.
- Risk of patient management: low risk of morbidity from additional testing or treatment.
A common example: a patient with well-controlled hypertension comes in for a routine check, the physician reviews a recent lab and continues the current plan. One stable chronic illness plus low risk supports 99213.
What Counts Toward Total Time?
Total time includes face-to-face and non-face-to-face work by the physician or qualified health professional on the date of the encounter. That covers preparing, reviewing records, examining, counseling, ordering, documenting, and care coordination. It does not include clinical staff time, or record review done on a different day.
If you code by time, the note has to state the total time. “Spent 25 minutes” with nothing else is weaker than a note that says what the time was spent on.
99213 vs. 99214: Where Practices Get It Wrong
99214 needs moderate MDM or at least 30 minutes. The jump from low to moderate usually comes from the problem element, such as a chronic illness with exacerbation or progression, or two or more stable chronic illnesses. Practices tend to make one of two mistakes:
- Undercoding: the physician manages two stable chronic conditions and orders labs, which can support 99214, but bills 99213 out of habit.
- Overcoding: 99214 is billed on time without the time documented, or with time that includes staff work.
Both show up in a billing audit. Undercoding costs you money every visit. Overcoding costs more when a payer finds it.
Billing 99213 With a Procedure
If a minor procedure happens at the same visit, 99213 is only separately payable when the E/M work is significant and separately identifiable from the procedure’s usual pre-procedure assessment. That’s what modifier 25 tells the payer, and it’s one of the most audited modifiers in outpatient billing.
For the code sets behind all of this, see our CPT, ICD-10, and modifier guide.
Frequently Asked Questions About CPT 99213
How many minutes is CPT 99213?
At least 20 minutes of total physician or qualified health professional time on the date of the encounter. CGS Medicare’s fact sheet lists 20-29 minutes, and 30 minutes or more moves the visit to 99214.
Can 99213 be billed for a new patient?
No. 99213 is for established patients only. New patient office visits use 99202 through 99205.
Does clinical staff time count toward 99213?
No. Only the physician’s or qualified health professional’s time on the date of the encounter counts. Clinical staff time is excluded.
What is the difference between 99213 and 99214?
99213 requires low medical decision making or at least 20 minutes. 99214 requires moderate medical decision making or at least 30 minutes.
What OmniBridge Actually Does
We review E/M level distribution across your providers, flag visits where the documentation supports a higher or lower level, and give feedback before claims go out, not after a payer letter.
If you think your practice bills 99213 by habit, request a free practice audit and we’ll show you what your notes actually support.
