99213—Established patient office visit, level 3
CPT 99213 is a mid-level office or telehealth visit for an established patient, billed for low-complexity decision-making or 20 to 29 minutes of the provider's time.
Reviewed by the ClinicsFlows editorial team · Updated July 15, 2026 · How we source this
Quick Facts
Code
99213
Category
Category I
Section
Evaluation & Management
Last reviewed
2026
What 99213 covers
99213 is a mid-level established patient office visit, the kind that makes up a big share of everyday outpatient care. You bill it when someone your practice has seen before comes in for a problem that takes real thought but isn't complicated. Think a known diabetic whose numbers drifted up, or a patient back to check on blood pressure pills. Since 2021 you pick the level one of two ways: the complexity of your medical decision-making, or the total time you spend on the visit that day.
For a level 3 visit, that means low-complexity decision-making, or 20 to 29 minutes of total time on the date of the encounter. Time counts your work before, during, and after the face-to-face part, as long as it lands on that same calendar day. The old scoring by history and exam went away in 2021. Your note still needs a history and exam that fit the problem, but they no longer set the level.
The payment covers the visit itself: hearing the patient out, reviewing results, and adjusting the plan. It does not cover a separate procedure done the same day, like a skin biopsy or a joint injection. Those carry their own code, and the visit needs modifier 25 to show it stood on its own. A first-ever visit isn't 99213 either. Brand-new patients use the 99202 to 99205 set.
Who uses it and when
Primary care runs on this code. A 58-year-old with high blood pressure comes back after starting a new pill, mentions some dizziness, and leaves with a lower dose and a lab order. That's a textbook 99213. So is a follow-up for a child's eczema that's mostly controlled but needs a refill and a few worried questions answered. Cardiology, neurology, and dermatology bill it the same way for stable, established patients who need a look and a small change.
Psychiatry leans on 99213 for medication management, often with the 90833 add-on when the same session includes 16 or more minutes of therapy. Two codes on one bill can rattle patients, so the chart has to show the therapy time as its own block. What a level 3 visit can't be is a first visit, a quick refill with almost no thought behind it (that's 99212), or a heavier visit with moderate decision-making or 30-plus minutes (that's 99214). Picking the wrong neighbor is the most common way this code gets the money wrong.
Documentation requirements
- The reason for the visit and a short history that matches the problem being managed.
- An exam focused on that problem, sized to what the visit actually called for.
- An assessment and plan for each problem, showing the thinking behind any medication or testing change.
- If you bill by time, the total minutes spent on the visit that day plus a line on what that time included.
- If you bill by decision-making, enough detail to support low complexity: the problems addressed, data reviewed, and any risk from the treatment.
- For a separate service the same day, a distinct note that supports modifier 25.
- The date of the encounter, since time-based billing counts only that one calendar day.
Common billing mistakes
Common modifiers with 99213
Modifiers change how a payer reads the code. These are the ones billers most often attach to 99213, and why.
Special billing rules for 99213
Rules that go beyond the basics — how 99213 interacts with add-on codes, supervision, and place of service. These are the ones that most often trip up a claim.
Pick time or decision-making, not both
Since 2021 you set the level by low-complexity decision-making or by 20 to 29 minutes of total time on the visit day. History and exam no longer decide it.
Modifier 25 for same-day services
When you also do a minor procedure or a therapy add-on like 90833, the visit needs modifier 25 to show it was separate, or the payer bundles it away.
Incident-to and split or shared billing
When a nurse practitioner or PA sees the patient, incident-to and split or shared rules decide whose name the claim bills under, which changes the payment.
Reimbursement & payer behavior
Work RVU
1.3
Total RVU
2.85
Medicare rate*
~$95.00
Global period
XXX
Concept doesn't apply to this code
*Approximate national non-facility rate, sourced from the CMS Medicare Physician Fee Schedule. Actual payment varies by locality and payer contract. Verify against the current fee schedule before billing.
Under the 2026 Medicare fee schedule, 99213 pays roughly $95 in an office (non-facility) setting nationally, built on about 1.30 work RVUs and a total near 2.85. Your actual check moves with your region, since Medicare adjusts every rate for local costs. Commercial plans set their own amounts, and the charge printed on a patient's statement usually sits far above what any plan allows, which is why a single 99213 can look alarming on an EOB before the discount lands.
This code sits in the middle of the most-audited family in medicine, so payment isn't automatic. Several large insurers now run software that drops level 4 visits to 99213, and some push 99213 down to 99212, often without opening the record first. Practices report winning most of these appeals when the note backs the original level, but the fight burns staff hours. Clean documentation is what gets you paid the first time and what wins the appeal when it doesn't.
Frequently asked questions about 99213
What is CPT code 99213 and what does it mean?▼
It's the code for a mid-level office visit with an established patient, one already in your practice's records. You bill it for either low-complexity decision-making or 20 to 29 minutes with the patient that day. It covers common follow-ups: stable blood pressure, a medication check, a controlled chronic condition. It's the most-used office visit code in the country.
Is CPT 99213 an E/M code?▼
Yes. It's an evaluation and management code in the office and outpatient visit family, which runs 99202 to 99215. The 99211 to 99215 range covers established patients, and 99213 sits in the low-to-middle of that set.
What is the time for CPT 99213?▼
20 to 29 minutes, counted as your total time on the encounter day. That spans the work before, during, and after the face-to-face part, all on that same date. You only need to hit the minutes if you're leveling the visit by time instead of by decision-making.
What modifier is used with 99213?▼
Modifier 25 is the common one, added when you also do a separate procedure or service the same day so the visit still gets paid. For telehealth, most commercial and Medicare Advantage plans want modifier 95, while original Medicare uses place-of-service codes instead. Modifier 24 applies when the visit falls inside another procedure's global period and is unrelated to it.
What is the difference between 99213 and 99212?▼
Complexity and time. 99212 fits straightforward decision-making or 10 to 19 minutes, a fast, simple visit. 99213 asks for low complexity or the 20-to-29-minute range, so there's a real problem being managed, not just a refill. When a visit sits on the line, the documented problems, data reviewed, and risk decide it.
How much does 99213 reimburse?▼
About $95 in an office setting under the 2026 Medicare fee schedule, before local adjustments. Commercial plans pay their own negotiated rates, higher or lower. The amount billed is often far above any allowed rate, so a patient's share is based on the plan's price, not the sticker number.
What is 99214, and how is it different from 99213?▼
99214 is the next level up for an established patient visit. It calls for moderate-complexity decision-making or 30 to 39 minutes, against low complexity or 20 to 29 minutes for 99213. A visit that adds a new problem, weighs a real risk, or reviews more data often earns 99214. This is the pair insurers most often downcode, so the note has to show the extra work.
Why was my 99213 downcoded, and can I appeal?▼
Yes, you can appeal, and many practices win. Insurers including Aetna have been auto-reducing higher-level visits to 99213, sometimes before anyone reviews the chart. If the record supports the level you billed, send it with the appeal and point to the decision-making or the time. Track your win rate, because these add up fast.
Why was I billed 99213 plus another code like 90833?▼
Because two separate services happened in one visit. 99213 covers the medical part, such as managing your medication, while 90833 covers 16 or more minutes of psychotherapy done at the same appointment. This pairing is normal in psychiatry. The notes should show the therapy time on its own, and you can ask your provider for that detail if the bill looks off.
More codes in the same specialties
Sources
- Fee and RVU data: CMS Medicare Physician Fee Schedule Lookup (2026 code set)
- Diagnosis codes: ICD-10-CM, published by CMS
- Telehealth status: Medicare Telehealth Services List
- Code set governance: American Medical Association — CPT
- How we research and verify: our editorial policy
CPT® is a registered trademark of the American Medical Association. Content on this page is original educational writing, not a reproduction of AMA-copyrighted descriptions. Reimbursement figures are approximate and for reference only. Verify with current payer contracts before billing.