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CPT_99213_Template

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CPT Code 99213 Documentation Template

Established Patient - Low Complexity Office/Outpatient Visit

Code Level: Low complexity E/M for established patients
Typical Time: 20-29 minutes total encounter time
2025 Medicare Reimbursement: $101.58
Requirement Method: Time-based OR Low-Complexity MDM (choose one)

⚠️ CRITICAL QUALIFICATION REQUIREMENTS

Patient Status

  • Established Patient Confirmed - Seen by this provider or another provider in same specialty/group within past 3 years
  • Office or Outpatient Setting - Private practice, clinic, urgent care (NOT facility/hospital)

Complexity Threshold (Must Choose One)

Option A: TIME-BASED CODING

  • Total encounter time: 20-29 minutes (includes face-to-face + non-face-to-face activities same day)
  • Document specific start/stop times or total time spent
  • List activities performed

Option B: LOW-COMPLEXITY MDM

  • Medical Decision-Making qualifies as LOW complexity (see MDM section below)
  • Document clinical reasoning and complexity drivers

SECTION 1: PATIENT DEMOGRAPHICS & VISIT INFO

Date of Service: _______________
Time In: _____________ Time Out: _____________ Total Time: _____________
Provider Name & NPI: _________________________________
Established Patient ID/MRN: _________________________
Chief Complaint: ________________________________________________

SECTION 2: HISTORY OF PRESENT ILLNESS (HPI)

Required: At least 2 HPI elements documented (for expanded history)

  • Location: Where is the patient experiencing symptoms?

  • Quality: How would the patient describe the symptom (sharp, dull, aching)?

  • Severity: Rate current vs. baseline (1-10 scale helpful)

  • Duration: When did this start? Is it constant or intermittent?

  • Modifying Factors: What makes it better or worse?

  • Associated Symptoms: Any other symptoms?

Clinical Context for 99213 Justification:

Document why this visit is appropriate for low complexity:

  • Stable chronic condition(s) with routine follow-up

    • Condition: _________________ Status: Stable / No change needed
    • Condition: _________________ Status: Stable / No change needed

  • Minor acute illness or complaint

    • Issue: _________________ Expected resolution: _________________________

  • Medication refill with no adjustments

    • Medications: ________________________________________________________________

SECTION 3: REVIEW OF SYSTEMS (ROS)

Expanded ROS Required: 2-5 organ systems reviewed and documented

Constitutional: [ ] Denies / [ ] Reports ________________________
Eyes: [ ] Denies / [ ] Reports ________________________
Ears, Nose, Mouth, Throat: [ ] Denies / [ ] Reports ________________________
Cardiovascular: [ ] Denies / [ ] Reports ________________________
Respiratory: [ ] Denies / [ ] Reports ________________________

Additional Systems (select as needed):
Gastrointestinal: [ ] Denies / [ ] Reports ________________________
Musculoskeletal: [ ] Denies / [ ] Reports ________________________

SECTION 4: PAST, FAMILY, AND SOCIAL HISTORY (PFSH)

Expanded PFSH Required: At least 1 element documented (established patient allows brief)

Past Medical History

Chronic Conditions:

  • Condition 1: _________________ Status: _________________________

Medications: (List current)

  1. _________________________ Indication: _________________
  2. _________________________ Indication: _________________
  3. _________________________ Indication: _________________

Allergies: [ ] NKDA / [ ] Document: _________________________________

Family History (brief or per HPI relevance)

Social History (brief or per HPI relevance)

Tobacco: [ ] Never [ ] Former [ ] Current
Alcohol: [ ] None [ ] Occasional [ ] Daily

SECTION 5: PHYSICAL EXAMINATION (PE)

Expanded Exam Required: 2-4 organ systems documented

Vital Signs:
BP: / HR: _____ RR: _____ Temp: _____ O₂ Sat: _____

General/Constitutional:
[ ] Well-appearing / [ ] Alert / [ ] Abnormal: ____________

Focused System Exam #1:
System: _________________ Findings: __________________________________

Focused System Exam #2:
System: _________________ Findings: __________________________________

Focused System Exam #3 (if applicable):
System: _________________ Findings: __________________________________

SECTION 6: ASSESSMENT & DIAGNOSIS

Primary Diagnosis: ____________________________________________
Diagnosis Code (ICD-10): ______________________________________

Secondary Diagnoses (if applicable):

  1. _________________________________ ICD-10: _____________________

SECTION 7: MEDICAL DECISION-MAKING (MDM) - COMPLEXITY JUSTIFICATION

Low-Complexity MDM Required: Meet 2 of 3 Categories Below

CATEGORY 1: NUMBER AND COMPLEXITY OF PROBLEMS ADDRESSED

✓ Check all that apply:

  • One or more self-limited or minor problems
    • Problem: _________________ Expected course: Resolves in days to weeks
  • Stable chronic illness(es) - no exacerbation or change
    • Condition: _________________ Status: Stable / Controlled

Point Achieved? [ ] YES - Category 1 Satisfied [ ] NO - Move to Categories 2 & 3

CATEGORY 2: AMOUNT AND COMPLEXITY OF DATA REVIEWED/ORDERED

✓ Must meet ANY combination of 2 from the following:

Tests/Documents Reviewed or Ordered:

  • Review of recent test result from chart: _______________________
  • Ordering of single test: ____________________________________
  • Brief review of prior visit summary or problem list: _________

Total items checked: _____/2 minimum needed

Point Achieved? [ ] YES - Category 2 Satisfied [ ] NO - Check Category 3

CATEGORY 3: RISK OF COMPLICATIONS/MORBIDITY/MORTALITY

✓ Check all that apply:

  • Prescription drug refill with no changes (established medication)

    • Drug: _________________

  • Over-the-counter medication recommendation or patient counseling

    • Topic: _________________

Point Achieved? [ ] YES - Category 3 Satisfied [ ] NO

MDM COMPLEXITY SUMMARY

Categories Satisfied:

  • Category 1 (Problem Complexity)
  • Category 2 (Data Review)
  • Category 3 (Risk Assessment)

Total Categories Met: _____/3 required = 2 minimum for LOW COMPLEXITY

✅ LOW COMPLEXITY MDM ACHIEVED [ ] YES [ ] NO

SECTION 8: CLINICAL REASONING & MEDICAL NECESSITY

Document why this patient requires only LOW-COMPLEXITY level care today:

Specific reason for visit (check applicable):

  • Routine medication refill - no changes needed
  • Follow-up of stable chronic condition
  • Minor acute complaint (expected to resolve quickly)
  • Monitoring of previously diagnosed condition - stable
  • Patient counseling on minor health topic
  • Other: ______________________________________________________

SECTION 9: PLAN & MANAGEMENT

Primary Plan:

Medication Management:

  • Continued: _________________ Indication: _________________
  • Refilled: _________________ Number of refills: _________
  • Counseled: No changes needed / Continue current regimen

Patient Instructions:

  • Activity level recommendations provided
  • Self-care instructions given
  • When to return/call explained

Follow-up:

  • Routine follow-up in: _____________ weeks/months
  • PRN for: ____________________

SECTION 10: TIME DOCUMENTATION (If Using Time-Based Coding)

Total Time Spent on Date of Service: ________________ minutes

Time Range for 99213: 20-29 minutes ✅

Breakdown of Time Spent:

ActivityMinutesDetails
Review prior records______________________
History taking_____Focused/Expanded HPI
Physical examination_____2-4 system exam
Medical decision-making_____Straightforward plan
Patient counseling/instruction______________________
TOTAL TIME_____≥20 minutes required

SECTION 11: CODING DECISION & JUSTIFICATION

Primary Coding Method Used:

  • TIME-BASED: 20-29 minutes total encounter (documented above)
  • MDM-BASED: Low-complexity medical decision-making (2 of 3 categories met)

Code Selection:

  • CPT 99213 - Established Patient, Low-Complexity E/M Visit

Compared to Other Established Patient Codes:

  • 99211: Brief visit (10-19 min), minimal complexity (NOT appropriate if more than brief)
  • 99213: Expanded history/exam, LOW complexity MDM ✅ APPROPRIATE
  • 99214: Detailed history/exam, moderate complexity MDM (NOT appropriate - over-coding)
  • 99215: Comprehensive history/exam, high complexity MDM (NOT appropriate - over-coding)

Audit Defense Checklist:

  • Medical necessity documented appropriately
  • No artificial complexity inflation
  • History/Exam/MDM components documented (minimal but present)
  • Consistency across documentation
  • Time documented clearly if using time-based method
  • Straightforward decision-making appropriately described

SECTION 12: PROVIDER SIGNATURE & CREDENTIALS

Provider Signature: ________________________ Date: __________

Printed Name: ___________________________

Credentials: ____________________________

NPI: ___________________________________

Specialty: ______________________________

Attestation: I personally performed/reviewed the key components of this evaluation and management service and attest that the documentation accurately reflects the complexity of this encounter and meets medical necessity criteria for CPT code 99213.

QUICK REFERENCE: COMMON 99213 SCENARIOS

Example 1: Routine Medication Refill

Documentation:

  • Chief Complaint: “Refill blood pressure medication”
  • HPI: Patient reports doing well, blood pressure controlled
  • PE: BP 128/82, HR 72, appears well
  • MDM: Continue lisinopril 10mg daily as prescribed
  • Plan: Refill medication x11 refills
  • Time: 22 minutes (brief review, vital signs, medication discussion)

Example 2: Stable Diabetes Follow-Up

Documentation:

  • Chief Complaint: “Diabetes check-up”
  • HPI: No polyuria, polydipsia, or foot pain
  • PE: Weight stable, feet intact, no edema
  • Review: Prior A1C 7.8%, blood glucose log stable
  • MDM: Continue current diabetes medications, routine monitoring
  • Plan: Continue metformin/glipizide, recheck A1C in 3 months
  • Time: 24 minutes (stable condition, straightforward plan)

Example 3: Acute Minor Illness

Documentation:

  • Chief Complaint: “Cold symptoms for 3 days”
  • HPI: Runny nose, mild cough, no fever
  • PE: HEENT: rhinitis, throat clear; Lungs: clear
  • Review: None needed - routine viral illness
  • MDM: Self-limited viral upper respiratory infection, supportive care
  • Plan: Rest, fluids, OTC decongestant as needed, return if worsens
  • Time: 21 minutes (focused acute visit)

Example 4: Follow-Up Chronic Condition - Stable

Documentation:

  • Chief Complaint: “Asthma check”
  • HPI: Using rescue inhaler rarely (1-2 times/week), no exacerbations
  • PE: Lungs clear bilaterally, no wheeze, oxygen saturation 98%
  • MDM: Well-controlled asthma on current regimen
  • Plan: Continue albuterol inhaler, fluticasone as prescribed
  • Time: 23 minutes (stable management visit)

KEY DIFFERENCES: 99213 vs 99214 vs 99215

Element99213 (Low)99214 (Moderate)99215 (High)
Time20-29 min30-39 min40-54 min
HistoryExpanded (2+ HPI)Detailed (3+ HPI)Comprehensive (4+ HPI)
ROSExpanded (2-5 sys)Detailed (6-9 sys)Comprehensive (10+ sys)
PFSHExpanded (1 elem)Detailed (1+ elem)Comprehensive (2-3 elem)
PEExpanded (2-4 sys)Detailed (5-7 sys)Comprehensive (8+ sys)
MDMLow (2 of 3)Moderate (2 of 3)High (2 of 3)
Best ForStable/routineMild exacerbationSevere/complex
Reimbursement$101.58$138.24$175.64

DECISION TREE: WHEN TO CODE 99213

START HERE: Is this an established patient office visit?

YES → Continue
NO → Not 99213 (use 99201-99205 for new patients, or 99211 for brief service)

Next: What is the complexity level?

LOW COMPLEXITY? →
  ✓ 1-2 stable chronic conditions
  ✓ Minor acute illness (viral cold, minor infection)
  ✓ Medication refill with no adjustment
  ✓ Routine follow-up with no changes
  → CODE 99213 ✅

MODERATE COMPLEXITY? →
  ✓ Multiple stable chronic conditions
  ✓ Mild exacerbation of chronic disease
  ✓ Recent diagnosis follow-up
  ✓ New symptom requiring evaluation
  → CODE 99214 (NOT 99213)

HIGH COMPLEXITY? →
  ✓ Severe exacerbation
  ✓ Multiple drug adjustments
  ✓ Extensive workup needed
  → CODE 99215 (NOT 99213)

COMPLIANCE REMINDERS ⚠️

✅ BEST PRACTICES FOR 99213

  • Document straightforward medical decision-making honestly
  • Don’t artificially inflate complexity
  • Clear, simple notes are appropriate for straightforward visits
  • Ensure 2-4 systems examined (expanded but not detailed)
  • Include at least 2 HPI elements
  • Document time clearly if using time-based method

❌ COMMON ERRORS TO AVOID

  • Over-documenting to inflate code (this triggers audits!)
  • Coding 99213 for truly straightforward visit when 99211 applies
  • Coding 99213 when patient actually has moderate complexity (should be 99214)
  • Missing required history or exam components
  • Inconsistent time documentation
  • Vague documentation (“patient stable” without supporting detail)
  • Not documenting what was actually reviewed/ordered

RED FLAGS: WHEN 99213 MIGHT BE WRONG

Consider downcode to 99211 if:

  • No physical examination performed
  • Only brief conversation/instruction
  • No medication management
  • Patient seen only for paperwork/administrative reason
  • Less than 20 minutes total time

Consider upgrade to 99214 if:

  • Multiple chronic conditions with any management change
  • Any new symptom or complication
  • Exacerbation of chronic disease (even mild)
  • Coordination with specialists
  • Complex medication regimen requiring evaluation
  • More than 30 minutes spent

AUDIT VULNERABILITY ASSESSMENT

99213 Notes at Lowest Audit Risk When:

  • ✅ Documentation is straightforward and honest
  • ✅ Time documented and matches complexity
  • ✅ No unnecessary complexity inflation
  • ✅ Consistent with chief complaint and assessment
  • ✅ Clearly stable chronic disease or minor acute illness

99213 Notes at HIGHER Audit Risk When:

  • ❌ Over-documented with 15+ systems examined
  • ❌ Multiple medication adjustments documented
  • ❌ Extensive data review mentioned
  • ❌ Inconsistent description (says “stable” but documents concerning findings)
  • ❌ Time documented as 29 minutes (at code ceiling) but visit seems quick

Template Last Updated: January 2026
Compliant with: 2021 AMA E/M Guidelines, CMS Standards

RESOURCES FOR MEDICAL CODERS

Official Sources:

  • American Medical Association (AMA) - CPT Guidelines
  • Centers for Medicare & Medicaid Services (CMS) - E/M Documentation Guidelines
  • Your payer-specific documentation requirements

Key Contacts:

  • Compliance Officer for coding questions
  • Billing Manager for policy clarification

This template is provided as a professional tool for medical documentation. Ensure compliance with your specific payer requirements, institutional policies, and applicable regulations. This is not legal or tax advice.

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