CPT 99213 Billing Guide 2025 - Requirements, Rates & Documentation

CMS 2026 Update — CPT 99213

CY2026 guidance for CPT 99213 (Established patient, low to moderate complexity) remains consistent: document history, exam, and medical decision-making proportional to the visit level.

What is CPT 99213?

CPT 99213 represents an established patient office or other outpatient visit — typically involving a low to moderate level of medical decision-making (MDM) and lasting approximately 15 minutes.

Typical uses: This code is used for follow-up visits, chronic condition management, and routine check-ups.

In short: CPT 99213 = Low to moderate MDM office visit for established patients.

When to Use CPT 99213 (and When Not To)

Use 99213 for established patient visits that require low to moderate MDM.

• Report when the visit involves reviewing and managing one or more chronic conditions.
• Documentation should reflect the complexity of the MDM and time spent.

Do not use for new patients or visits requiring high complexity MDM.

Clinical Examples

• Follow-up for hypertension management → 99213
• Initial consultation for diabetes → 99201

99213 vs 99214 (Quick Comparison)

2025 Reimbursement Rates (Representative)

Documentation Guidelines (CMS & MIPS 2025 Compliant)

Thorough documentation demonstrates medical necessity, skilled care, and functional intent. Include:

1. Functional goal (e.g., “Patient will maintain blood pressure within normal range”).
2. Activity description — explicit tasks practiced, environment, and level of assistance.
3. Clinical rationale — why this activity addresses the patient’s deficit.
4. Time documentation — minutes per activity and total minutes (apply the 8-minute rule for units).
5. Patient response — tolerance, cues required, measurable progress.

Sample SOAP Note (De-identified)

S: Patient reports feeling well, with occasional headaches.
O: Blood pressure is 130/85, heart rate 72 bpm.
A: Hypertension is well-controlled with current medication regimen.
P: Continue current medications, follow-up in 3 months.
  

Modifiers & Coding Tips

Claim tip: Ensure documentation supports the use of modifiers to avoid denials.

Common Denials & How to Prevent Them

1. Insufficient documentation — Fix: Ensure all elements of the visit are documented clearly.
2. Incorrect modifier usage — Fix: Verify that modifiers are applied correctly and supported by documentation.
3. Non-covered service — Fix: Confirm coverage with the payer before the service is rendered.

Audit trigger: Frequent use of modifiers without clear documentation.

Region & Local Payer Notes

In New York, ensure compliance with CGS MAC - Jurisdiction 6 guidelines. Local policies may affect reimbursement rates and documentation requirements. Always verify with local MAC for specific guidance.

FAQs

How to justify a 99213?

99213 reflects a visit with low to moderate complexity; document the problem-focused history, exam, and MDM elements supporting the level.

Can 99213 be used for chronic disease follow-up?

Yes — it is commonly used for routine chronic disease management when issues are stable or moderately complex.

What documentation helps avoid denials?

Include concise documentation of the problem, assessment, and plan, plus any counseling or coordination details.

Is counseling counted for time-based billing?

Counseling and coordination can support time-based billing if they dominate the visit; document total time and content covered.

How to code when procedures are performed?

If a minor procedure occurs, document both the procedure details and the E/M components to determine appropriate coding or global billing.

How to handle phone or portal follow-ups?

Billing for non-face-to-face services varies by payer and may use different codes; document the interaction and any resulting plan changes.