June 6, 2025

CPT 99213 Billing Guide 2025 - Requirements, Rates & Documentation

CPT Code 99213 is part of the Current Procedural Terminology (CPT) coding system maintained by the American Medical Association (AMA). This code is used to describe a level 3 office or other outpatient visit for the evaluation and management of an established patient. The 99213 code specifically denotes a moderate complexity of service provided during a typical office visit.

Top Healthcare payers for CPT Code

99213

Disclaimer: Reimbursement rates are estimates and vary by payer, location, and case.

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📊 CPT 99213 Quick Facts (2025)

Code Category:
Evaluation & Management (E&M)

Patient Type:
Established patients only

Typical Duration:
15 minutes face-to-face

Complexity Level:
Moderate (Level 3)

2025 Updates: What's Changed for CPT 99213

🆕 Key Changes for 2025:

Updated Documentation Requirements: Enhanced specificity needed for medical decision-making
Telehealth Expansion: New modifier requirements for virtual visits
Reimbursement Adjustments: Medicare rates updated across all localities
Audit Focus: Increased scrutiny on E&M code documentation

What is CPT Code 99213?

CPT 99213 is a Level 3 Evaluation and Management (E&M) code for established patients receiving moderate-complexity care in office or outpatient settings. This code specifically applies to patients who have been seen by the practitioner or another provider within the same group practice within the last three years.

As part of the Current Procedural Terminology (CPT) coding system maintained by the American Medical Association (AMA), 99213 standardizes billing for moderate-complexity patient encounters, ensuring consistent communication between healthcare providers, insurers, and patients.

✅ Step-by-Step CPT 99213 Billing Process

Verify Patient Status: Confirm patient is "established" (seen within 3 years by provider or same-specialty colleague)

Document History: Conduct expanded problem-focused history including chief complaint and relevant updates

Perform Examination: Complete expanded problem-focused examination relevant to patient's condition

Medical Decision Making: Document low-complexity medical decision making with treatment adjustments

Submit Claim: Bill CPT 99213 with appropriate modifiers and documentation support

2025 CPT 99213 Reimbursement Rates by Payer

Insurance Payer	Average Reimbursement	Prior Auth Required	Denial Rate
Medicare Part B	$87.20	❌ No	3.2%
Aetna PPO	$78.50	❌ No	2.8%
BCBS (Average)	$72.30	❌ No	4.1%
UnitedHealthcare	$69.80	❌ No	3.9%
Cigna	$45.20	❌ No	5.2%

💰 Pro Tip: The average CPT 99213 reimbursement across all payers is $70.60. Negotiate higher rates by demonstrating quality outcomes and patient satisfaction scores.

Essential Documentation Requirements for CPT 99213

Proper documentation is crucial for CPT 99213 reimbursement and audit protection. Here are the core requirements:

1. Expanded Problem-Focused History

Required Elements:

Chief Complaint: Primary reason for today's visit
History of Present Illness: Detailed symptom progression since last visit
Review of Systems: Relevant system review (2-9 systems)
Past Medical History: Updates to medical history, medications, allergies

Example: "Patient returns for follow-up of chronic low back pain. Reports 30% improvement since starting PT 3 weeks ago. Pain now 4/10 vs previous 7/10. Able to walk 2 blocks without stopping."

2. Expanded Problem-Focused Examination

Documentation Must Include:

Vital Signs: At least 3 vital signs documented
Constitutional: General appearance and behavior
Affected System(s): Detailed examination of problem area(s)
Additional System: At least one additional system examined

3. Medical Decision Making (Low Complexity)

Components Required:

Assessment: Clear diagnosis or differential diagnosis
Plan: Treatment plan with specific interventions
Risk Level: Low to moderate risk of complications
Data Review: Analysis of test results or external records

Common CPT 99213 Billing Errors & How to Avoid Them

⚠️ Error #1: Insufficient Documentation

Problem: Missing required elements for moderate complexity level

Solution: Use documentation templates and conduct regular internal audits

⚠️ Error #2: Incorrect Patient Classification

Problem: Using 99213 for new patients or those not seen in 3+ years

Solution: Verify patient history in EMR before coding

⚠️ Error #3: Missing Time Documentation

Problem: Not documenting the 15-minute face-to-face time requirement

Solution: Always document total encounter time and counseling time

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Frequently Asked Questions

What documentation is required for CPT 99213?

CPT 99213 requires expanded problem-focused history, expanded problem-focused examination, and medical decision making of low complexity. You must document the patient's chief complaint, relevant history updates, physical examination findings, assessment, and treatment plan. Face-to-face time of approximately 15 minutes should also be documented.

How much does CPT 99213 reimburse in 2025?

CPT 99213 reimbursement ranges from $45-90 depending on the payer and geographic location. Medicare typically reimburses around $87, while commercial payers average $70-80. Medicaid rates are generally lower at $45-60 per encounter.

Can CPT 99213 be billed with other E&M codes on the same day?

Generally, no. CPT 99213 cannot be billed with other E&M codes for the same patient on the same day unless the encounters are for unrelated problems and documented separately. Use modifier -25 only when a significant, separately identifiable E&M service is performed on the same day as a procedure.

What modifiers are commonly used with CPT 99213?

Common modifiers include: -25 (significant separately identifiable E&M service), -57 (decision for surgery), -95 (telehealth), and -GT (telehealth when required by payer). Always verify payer-specific modifier requirements before submission.

How often can CPT 99213 be billed per patient?

There are no specific frequency limitations for CPT 99213, but each encounter must be medically necessary and appropriately documented. Most payers allow multiple 99213 visits per year as long as the services meet the code's requirements and support the patient's treatment plan.

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With 15+ years of clinical and non-clinical expertise, has worked across physician-owned practices, home health, and virtual care dedicated to empowering providers and patients with optimal tools for movement health.

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