CPT 99213 Billing Guidelines and Documentation Requirements

CPT 99213 is one of the most commonly billed outpatient evaluation and management (E/M) codes in the United States. It represents an established patient visit that typically involves low-complexity medical decision making (MDM) or 20–29 minutes of total provider time. Physicians use this code for routine follow-ups, chronic condition management, medication adjustments, and symptom-focused visits. Accurate use of 99213 ensures proper reimbursement while reducing the risk of claim denials or audit issues.

This guide provides a detailed 99213 code description, billing guidelines, documentation rules, and practical examples to help physicians document efficiently and comply with payer requirements.

CPT 99213 Code Description

The CPT 99213 code description defines it as an established patient visit requiring either low-complexity MDM or 20–29 minutes of provider time. A visit qualifies as 99213 when the patient has one stable chronic illness, an uncomplicated acute problem, or a new problem that does not require extensive evaluation.

In practice, CPT 99213 is used for scenarios such as hypertension follow-ups with medication adjustment, diabetes management visits, rash evaluation without systemic complications, or depression follow-ups with brief symptom review. Physicians should avoid using 99213 when visits involve multiple chronic conditions requiring moderate complexity MDM, extensive data review, or increased risk interventions; these cases typically qualify for 99214.

Core criteria include:

1. Problems addressed: One stable chronic condition or an uncomplicated acute problem.
2. Data reviewed: Minimal to low (for example, prior notes, labs, or imaging).
3. Risk: Low risk of morbidity, including routine medication management.

99213 Documentation Requirements

Physicians can bill 99213 based on MDM or total time spent on the date of service.

Medical Decision Making (MDM)

Documentation must clearly demonstrate low-complexity MDM. Notes should describe the status of the problem, data reviewed, and risk level. For example, a provider might note:

“Low-complexity MDM: Evaluated one stable chronic condition with medication adjustment and review of prior labs.”

MDM documentation should include:

Problem assessment: Describe whether the condition is controlled, worsening, or stable.

Data review: Include labs, imaging, and prior records as relevant.

Risk: Document interventions, medication adjustments, or counseling performed.

Time-Based Billing

When using total time, documentation should indicate minutes spent on:

1. Reviewing patient chart and prior records
2. Conducting the patient interview and exam
3. Providing counseling
4. Ordering labs or imaging
5. Recording findings in the EHR

For example:

“Total time spent on the date of service: 23 minutes, including chart review, patient evaluation, counseling, medication adjustment, and documentation.”

Required Note Elements

A compliant 99213 note should include the reason for the visit, assessment, plan with rationale, patient instructions, and follow-up interval.

How to Document CPT 99213

Practical documentation examples make coding clear and defensible.

Primary Care Example (Hypertension Follow-Up):
The patient reports adherence to medications and mild headaches have resolved. Blood pressure is 132/82 with no acute findings. The assessment is essential hypertension, stable. The plan includes continuing current medications, reinforcing dietary counseling, and ordering labs. Low-complexity MDM is noted, with 21 minutes total time documented.

Cardiology Example (Palpitations Follow-Up):
The provider reviews Holter results showing improvement, with no medication changes required. The plan documents low-risk follow-up and totals 22 minutes of provider time.

Dermatology Example (Rash Evaluation):
A stable localized rash without systemic symptoms is assessed. Topical medication refill is provided, triggers are discussed, and counseling is included. The MDM remains low, supporting 99213.

99213 vs 99214 — Key Differences

Understanding when a visit qualifies for 99213 versus 99214 is critical. 99214 requires moderate complexity MDM or 30–39 minutes of provider time. Moderate complexity generally involves multiple chronic conditions, significant data review, or interventions with higher risk.

For instance, a visit that adjusts medications for both hypertension and diabetes, reviews an external cardiology report, and involves moderate-risk decisions may qualify for 99214. By contrast, a single chronic condition with low-risk management fits 99213.

Telehealth Billing Rules for CPT 99213

Telehealth visits are eligible for 99213 when documentation meets MDM or time criteria. Place of Service codes vary by payer (typically POS 02 or POS 10), and most telehealth visits require modifier 95 for synchronous encounters. Total time should include chart review, virtual exam, counseling, and documentation.

Common Denials & Audit Triggers

Common reasons for 99213 claim denials include insufficient MDM documentation, missing risk statements, incomplete data review, lack of time documentation, or incorrect modifier use. Physicians can protect their claims by following a quick audit-proof checklist:

1. Clearly state problem status
2. Document risk level and interventions
3. List data reviewed
4. Include total time if billing by time
5. Ensure assessment and plan show clinical decision-making

For denials, sample appeal language can help:

“Documentation supports low-complexity MDM with one stable chronic condition and a medication adjustment. Total provider time: 23 minutes. Request reconsideration.”

Medicare & Payer Reimbursement Overview

Reimbursement for CPT 99213 varies by payer and location. Medicare national averages typically range from $90 to $110, while commercial plans often pay $100–$150. Differences depend on geographic practice cost index (GPCI), contract rates, and office versus hospital setting. Providers should verify rates through payer fee schedules or provider portals.

FAQs About CPT 99213

What is CPT 99213 used for?
It represents an established patient visit requiring low-complexity MDM or 20–29 minutes of provider time.

What qualifies as a 99213 visit?
One stable chronic condition or an uncomplicated acute problem with low risk and minimal data review.

Is time required to bill 99213?
No, the visit can be billed based on MDM or total time.

Can I bill 99213 for telehealth?
Yes, using POS 02 or 10 and modifier 95 as required by the payer.

What is the time range for 99213?
20–29 minutes of total provider work.

Does prescription refill qualify for 99213?
Yes, if the visit meets low-complexity MDM criteria.

What's the difference between 99213 and 99214?
99214 requires moderate MDM or 30–39 minutes of total provider time.

Can new patients be billed under 99213?
No. 99213 is for established patients only.

Is a physical exam required?
Only as clinically relevant; MDM or time determines the code.

Are labs required for 99213?
No, but minimal data review may support MDM documentation.

Author Bio

Travis A., Senior Medical Billing Strategist with 10+ years of experience in U.S. E/M coding, payer contracting, and compliance. Helps practices reduce denials, improve audit readiness, and optimize documentation for accurate reimbursement.