🧬 CPT Code 99213 - established patient, low to moderate complexity

Office/Outpatient E/M Visit - Established Patient, moderate Complexity

Last Updated: February 2026
Status: 2025 Medicare Fee Schedule Compliant
Specialty Tags:

⚡ Quick Reference

Metric	Value	Notes
Global	XXX	No Global(Watch for Mod -57/-79)
wRVU	1.30	Professional
Assist	No	(Assistant modifiers 80, 81, 82, AS do not apply)

🚧 Bundling & NCCI Edits

(What is INCLUDED in this code?)

Includes: well visits, sick visits, follow-ups
Mutually Exclusive: Cannot be billed on the same day as other E/M codes (e.g., 99214, 99203, 99212) by the same provider for the same patient.

📝 MCW/Payer Specifics

(Documentation requirements to prevent downcoding)

Medical Necessity: Documentation must support [Severity/Complexity].
Time/MDM: For this level, ensure relevant history and MDM are clearly defined.
Modifier -22: Documentation must support >50% extra time/effort due to [BMI/Adhesions/Trauma].

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CPT 99213 Quick Reference Guide (2025/2026)

Code: 99213 Type: Evaluation and Management (E/M) Patient Status: Established Patient

Official Definitions

Long Definition:

Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter.

Short Definition: Established patient office visit, low MDM, 20-29 min.

Key Requirements (Billing Criteria)

To bill 99213, you must meet ONE of the following two criteria (MDM or Time):

1. Medical Decision Making (MDM)

Must meet 2 out of 3 elements of Low Complexity:

Problems: Low number and complexity (e.g., 2 minor self-limited problems; 1 stable chronic illness; 1 acute uncomplicated illness/injury).
Data: Limited amount of data to be reviewed and analyzed (e.g., ordering/reviewing 2 unique tests or documents).
Risk: Low risk of morbidity from additional diagnostic testing or treatment (e.g., Over-the-counter drugs, physical therapy, minor surgery with no risk factors).

2. Time (Total Time)

Range: 20-29 minutes.
Includes: Face-to-face time AND non-face-to-face time spent by the provider on the same day (e.g., reviewing records, documenting, ordering meds, communicating with other professionals).
Excludes: Time spent by clinical staff.

Common Use Cases

Stable Chronic Conditions: Routine follow-up for well-controlled hypertension, diabetes, or hyperlipidemia.
Minor Acute Injuries: Evaluation of a minor ankle sprain or uncomplicated lower back strain.
Medication Management: Refilling prescriptions with no or minor changes.
Infections: Uncomplicated URI, otitis media, or simple UTI.

Differentiation (99213 vs. 99214)

99213 (Low): Patient is stable; 1 chronic condition; OTC meds; “Run of the mill” visit.
99214 (Moderate): Patient is exacerbating; 2+ chronic conditions; Prescription drug management (new RX or dosage change); Systemic symptoms.

Documentation Tips

History & Exam: “Medically appropriate” (no longer scored by bullet points/elements).
Time: Must document exact total minutes if billing by time (e.g., “I spent 25 minutes total time…”).
MDM: Explicitly state the status of the problem (e.g., “Stable,” “Worsening”) to support the complexity level.

Key Requirements

Coding is based on either the total time spent by the provider on the day of the encounter or the Level of Medical Decision Making (MDM).

Medical Decision Making: Requires a “Low” level of MDM, which is met by satisfying two of the three elements: Low complexity of problems (e.g., one stable chronic illness), low amount/complexity of data, or low risk of complications.
History and Exam: Must be “medically appropriate” as determined by the provider; however, the extent of history and examination no longer dictates the code level.
Use Cases: Routine follow-ups for controlled chronic conditions (e.g., hypertension, Type 2 diabetes), simple acute illnesses (e.g., sinusitis, uncomplicated UTI), or minor injuries.

Exclusions and Bundling

Under the National Correct Coding Initiative (NCCI), 99213 is often subject to bundling edits with other procedures performed on the same day.

Mutually Exclusive Codes: It cannot be billed with other E/M codes (like 99214 or 99203) for the same patient on the same day by the same provider. It is also bundled into “major” surgical procedures (those with 10- or 90-day global periods) unless the visit is for a completely unrelated problem.
Assistant at Surgery: The “Assistant Surgeon” concept (Modifiers 80, 81, 82, or AS) is not applicable to 99213. Assistant modifiers are restricted to surgical procedure codes where an assistant is medically necessary; E/M codes are considered professional services inherent to the attending provider.
Modifier 25: This is required if 99213 is performed on the same day as a “minor” procedure (e.g., an injection or simple repair) to indicate that the E/M service was a “significant, separately identifiable” service.

Long Definition

“Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded”.

Explorer

99213