CPT® Code 99213

Last Updated: January 2026 | Verified for 2026 AMA, CPT & CMS Guidelines

Key Takeaways

• What it is: CPT 99213 is a level 3 established patient office/outpatient E/M visit. It requires a medically appropriate history and/or exam and either low complexity MDM or 20-29 minutes total time on the date of service.
• 2021+ framework: Code selection is based on MDM or time (not the former "history/exam bullets"). "Low MDM" means the encounter meets 2 of 3 MDM elements at the low level (problems, data, risk).
• Documentation focus: Notes must support medical necessity and clearly show: (1) status of problems addressed, (2) data reviewed/ordered/independently interpreted (if any), and (3) risk and treatment decisions. When coding by time, state the total minutes and the day-of-service activities included.
• Common use cases: Routine follow-ups for stable chronic illness and uncomplicated acute conditions are typical. Borderline 99212 vs 99213 decisions frequently hinge on whether the problem required provider-level evaluation and whether the record demonstrates low MDM or >=20 minutes of total work.
• Modifiers you must get right:
  • -25 when billing 99213 with a same-day minor procedure and the E/M is significant and separately identifiable.
  • -95 for synchronous audio-video telehealth (with appropriate POS) where payer rules require it.
  • -24 for an unrelated E/M service during a post-op global period (strictly unrelated to the surgery/aftercare).

What is CPT 99213? (Code Definition)

CPT 99213 is an office or other outpatient E/M visit for an established patient. The 2026 descriptor states the service requires a medically appropriate history and/or examination and a low level of medical decision making. If time is used for selection, it corresponds to 20-29 minutes of total time on the date of the encounter.

Operationally, 99213 is commonly the "workhorse" established-patient visit level: it fits encounters that are more involved than a brief, minimal visit (often 99212), but that do not rise to the moderate complexity that defines 99214. The key is that 99213 is not defined by how long the patient talks, how many templates are filled, or how many review-of-systems items are copied forward. It is defined by either low MDM or documented total time in the 20-29 minute range.

The "established patient" designation generally means the patient has received professional services from the physician/QHP or another provider of the same specialty in the same group within the prior 3 years. In day-to-day coding, the established/new distinction is a gatekeeper: even if the visit complexity feels like "level 3," you must still pick from the established code family (99212-99215) once the patient is established.

Typical 99213 problems include a stable chronic condition being monitored (for example, controlled hypertension or stable diabetes without complications) and uncomplicated acute complaints (for example, acute upper respiratory infection) where the decision making remains low complexity, the data reviewed is limited, and the risk is low. That said, 99213 is not "automatic" for these diagnoses; it depends on what was actually addressed and documented, including the status of the condition and the management decisions made.

MDM Criteria and Time Requirements

flowchart TD
    A[Established Patient E/M Visit] --> B{Select coding method}
    B -->|MDM-based| C{Low Complexity MDM?<br/>Meet 2 of 3 elements}
    B -->|Time-based| D{Total time on<br/>date of service?}
    C -->|Problems: 1 stable chronic<br/>or 1 acute uncomplicated<br/>or 2+ minor| E[Problems = Low]
    C -->|Data: limited review<br/>or simple test ordered| F[Data = Limited]
    C -->|Risk: low potential<br/>for complications| G[Risk = Low]
    E & F & G --> H{At least 2 of 3<br/>elements at Low?}
    H -->|Yes| I[Report 99213]
    H -->|No - all minimal| J[Consider 99212]
    H -->|No - 2+ moderate| K[Consider 99214]
    D -->|10-19 min| J
    D -->|20-29 min| I
    D -->|30-39 min| K
    I --> L{Same-day procedure?}
    I --> M{Telehealth visit?}
    I --> N{Within post-op global?}
    L -->|Yes, separate E/M| O[Add modifier -25]
    M -->|Synchronous A/V| P[Add modifier -95]
    N -->|Unrelated problem| Q[Add modifier -24]

Under the 2021+ AMA office/outpatient E/M rules (adopted for Medicare office/outpatient visits), you select 99213 by either: (A) documenting low complexity MDM, or (B) documenting 20-29 minutes total time on the date of service. You may choose whichever method best reflects the encounter; you do not have to "force" time if MDM is clearly low, and you do not have to "force" MDM if the time clearly meets the threshold and the work was medically necessary.

Low Complexity MDM (99213)

"Low MDM" means the overall MDM level is low based on 2 of 3 elements: (1) number/complexity of problems addressed, (2) amount/complexity of data, (3) risk of complications and/or morbidity/mortality of patient management.

The AMA MDM grid is the core reference for how problems/data/risk map to each level, including the "low" row typically associated with 99213.

• Problems addressed (low): Common low-level patterns include:
  • 1 stable chronic illness (for example, hypertension controlled on current therapy)
  • 1 acute uncomplicated illness or injury (for example, acute sinusitis without systemic symptoms)
  • 2 or more self-limited/minor problems addressed in the same visit These examples align with the AMA MDM framework for low complexity.
• Data reviewed/ordered (limited): Low MDM usually involves "limited" data, such as reviewing a small number of tests/documents, ordering a simple test, or needing an independent historian in appropriate cases. The practical coding point is that if you rely on data to support the level, you must actually document what you reviewed/ordered and why it mattered.
• Risk (low): Low-risk management decisions are those with low potential for serious complications. Many 99213 visits involve conservative measures, self-care counseling, OTC recommendations, simple follow-up planning, or straightforward prescriptions where the overall scenario remains low complexity. The risk element should reflect the management decisions actually made, not the diagnosis label alone.

Borderline nuance that matters: One element at a higher level does not automatically "upgrade" the visit. MDM is set by 2 of 3 elements. For example, if risk is arguably moderate (e.g., prescribing medication) but both problems and data remain low, the overall MDM can still be low in many routine outpatient patterns. You must document clearly enough that an auditor can see which elements support the final level.

Total Time (20-29 minutes)

If you select 99213 by time, the total provider time on the date of encounter must be at least 20 minutes and less than 30 minutes. Total time includes face-to-face and qualifying non-face-to-face time on the same date related to that patient's care (for example reviewing records, documenting, counseling, ordering tests, communicating with the patient/family), consistent with AMA/CMS guidance.

When using time, the record should state the total minutes and should plausibly reflect that work. Reviewers may compare the time statement to the content and complexity of documentation, and to whether the stated tasks are present in the note. Noridian's E/M guidance emphasizes that documentation should support medical necessity and the reported time when time-based coding is used.

A practical approach that reduces audit friction is to document both: (a) the visit's core MDM (problems/data/risk), and (b) total time when the visit is time-heavy.

You still select by one method, but having both in the note often makes the claim more review-resistant.

Documentation Guidelines and Examples

Documentation for 99213 should be built to answer a reviewer's questions quickly: (1) What problems were addressed, and what was their status? (2) What data did the provider review or order, if any? (3) What decisions were made and what was the risk level?

The goal is not to generate long notes; it is to create notes that are specific, internally consistent, and tied to medical necessity.

Medically appropriate history and/or exam

The history/exam no longer determines the code level, but it still matters for medical necessity and credibility. Your history and exam should be "medically appropriate," meaning the elements documented should logically connect to the complaint(s) and management decisions.

Over-documenting unrelated systems can look templated; under-documenting can make time statements or decision making look unsupported.

Document the status of each problem (not just the name)

For chronic problems, explicitly state whether the condition is stable, improving, or worsening. For acute problems, state whether the presentation is uncomplicated and whether red flags are absent. This "status" language is one of the most efficient ways to support the "problems" element of MDM and to show why the visit required provider-level evaluation.

Make data review visible

If you reviewed labs, imaging, or prior notes, document what you reviewed and why it mattered (for example "reviewed A1c 6.9%" rather than "labs reviewed").

If no data were reviewed or ordered, do not invent data language; simply leave that element minimal and let problems/risk (or time) support the code.

Time-based documentation that holds up

If selecting by time, include a statement like: "Total time = 24 minutes (reviewed prior labs, performed evaluation, counseled patient, documented encounter)."

This aligns with best-practice guidance and helps reviewers understand what the time represents. The time statement should be credible relative to the note content and visit context.

Audit-resistant 99213 example (stable chronic condition)

CC: Hypertension follow-up. Assessment: Essential hypertension (I10) - stable, controlled; no symptoms, home readings at goal. Data: Reviewed recent BMP; renal function at baseline. Plan: Continue current regimen, reinforce diet/exercise, follow-up interval specified. Time (if used): Total time = 20 minutes (reviewed BP log, counseled, documented).

Why it supports 99213: One stable chronic illness + limited data + low risk management supports low MDM; time statement also meets 20-29 minutes.

ICD-10 Diagnosis Examples for 99213

ICD-10 codes do not determine the E/M level by themselves, but payers often use diagnoses as context. The same diagnosis can support different visit levels depending on severity, stability, and management. That said, the following categories frequently align with low complexity 99213 patterns when documented as stable/uncomplicated:

• Stable chronic illness: I10 (essential hypertension), E11.9 (type 2 diabetes without complications), uncomplicated asthma patterns. These fit low MDM when stable and managed conservatively.
• Acute uncomplicated illness/injury: J06.9 (acute URI), uncomplicated sinusitis patterns, minor sprains with conservative management. These often remain low complexity when there are no systemic symptoms and limited workup is required.
• Multiple minor complaints: Two self-limited/minor problems can still be low complexity if the data reviewed is minimal and risk remains low (for example OTC-based management) per the MDM framework.

A common compliance failure is using 99213 for visits where the record shows almost no provider-level work (for example "BP check, continue meds" with no status, no relevant exam, no plan detail). In those cases, a payer may argue the service looks like 99212 or even a nurse visit. Conversely, if documentation shows moderate complexity (multiple chronic conditions, exacerbation, extensive data, or riskier management), 99214 may be more appropriate; the record should match the code selection to avoid downcoding or allegations of systematic miscoding.

Using Modifiers 25, 95, 24 with 99213

Modifier -25 (same day as a minor procedure)

Append modifier -25 to 99213 when, on the same date as a procedure or service, the E/M is significant and separately identifiable beyond the pre-/post-work inherent to the procedure. AMA guidance emphasizes that -25 is appropriate when the E/M is distinct, and that different diagnoses are not required.

Documentation should effectively show two services: (1) the separately identifiable E/M (history/exam/MDM or time), and (2) the procedure note elements. Overuse or routine appending of -25 without clearly separate E/M content is a known audit trigger in many payer programs.

Modifier -95 (telehealth, synchronous audio-video)

For video telehealth visits, many payers require modifier -95 to indicate the service was provided via synchronous audio-visual technology. The Medicare Telehealth Billing Guide provides practical billing examples, including 99213 as telehealth-eligible with modifier 95 and appropriate POS (02 or 10, depending on patient location and payer rules).

Telehealth documentation should state that the encounter was performed via live audio-video, and should record location/consent elements as required by payer policy. The clinical documentation (problem status, MDM, time) should be the same quality as an in-person note.

Modifier -24 (unrelated E/M during post-op global)

Append modifier -24 when the patient is within a post-operative global period and the E/M visit addresses a problem that is unrelated to the procedure and its aftercare. Guidance on applying -24 stresses the need to clearly establish "unrelatedness" through diagnosis selection and documentation narrative.

Medicare global surgery policy is often interpreted strictly: routine post-op care is bundled, and many complication-related services are also considered related. If the issue is not truly unrelated, -24 is inappropriate and can lead to denial or recoupment. If you use -24, explicitly document that the presenting problem and management are unrelated to the surgery.

Payer-Specific Guidelines (Medicare & Others)

Medicare adopted the 2021+ AMA office/outpatient E/M approach for MDM/time selection for codes like 99213, and contractor education materials emphasize that reviewers assess both medical necessity and the support for the reported MDM/time in the record.

• One E/M per day patterns: Many payers (including Medicare, depending on circumstances and edits) typically expect only one office/outpatient E/M per provider/specialty per patient per day, with exceptions in defined situations (for example different specialties, or separate facility rules). If two encounters occur, documentation must support why coding should not be consolidated.
• Distribution scrutiny: Payers may review coding distributions (for example nearly all established visits billed as 99213). This is not automatically wrong, but it can trigger requests for records if the pattern deviates from peers or appears inconsistent with diagnosis mix. Practical billing commentary sources frequently advise practices to avoid "habit coding" and to ensure documentation shows why each visit meets the chosen level.
• 99213 vs 99214 audit attention: Compliance-focused commentary anticipates increased scrutiny of borderline 99213/99214 decisions as payer audits evolve with newer fee schedule and oversight trends. The best mitigation is consistently documenting problem status, data, and risk (or time).

The most reliable "payer rule" strategy is to treat 99213 as a documentation-driven code: if the chart makes the low MDM clear (or the time clear), claims are more resilient across payers, and denials are less likely to depend on subjective interpretation.

Comparison: 99212 vs 99213 vs 99214

In practice, the easiest way to separate 99213 from 99212 is to ask whether the note demonstrates provider-level evaluation and management that goes beyond minimal reassurance, and whether the problems addressed and plan show low complexity rather than "straightforward." The easiest way to separate 99213 from 99214 is to check whether at least two MDM elements are truly moderate, or whether total time reaches 30 minutes or more.

Real-World 99213 Coding Scenarios

Scenario 1: Stable hypertension follow-up (MDM-driven)

Visit: Established patient follow-up for I10. BP controlled; no symptoms; adherence reviewed. Data: Reviewed recent BMP (kidney function baseline). Plan: Continue medication; reinforce lifestyle; routine follow-up. Why 99213: One stable chronic illness + limited data + low risk management supports low MDM.

Scenario 2: Acute uncomplicated URI with counseling (time-driven)

Visit: Viral URI counseling-heavy visit; no red flags; supportive plan; return precautions documented. Total time: 23 minutes (reviewed history, evaluated, counseled, documented). Why 99213: Time meets 20-29 minute threshold for 99213 regardless of whether MDM is at the low end.

Scenario 3: Same-day minor procedure + E/M (modifier -25)

Visit: Patient evaluated for two issues: stable chronic condition management plus a minor procedure performed (e.g., lesion treatment). Coding: 99213-25 + procedure code. Why it pays: The E/M is separately identifiable and supported by its own problem status and plan; -25 indicates it is beyond the usual procedure work.

Scenario 4: Telehealth established visit (modifier -95)

Visit: Video follow-up for stable chronic disease and symptom review; total time 26 minutes. Coding: 99213-95 with appropriate POS per payer requirements. Authority: Medicare telehealth billing guidance includes 99213 among telehealth-eligible services and shows the modifier/POS reporting approach.

Scenario 5: Unrelated problem during global period (modifier -24)

Visit: Patient within a post-op global period presents for a new, unrelated complaint (e.g., shoulder pain) evaluated by the operating/same-specialty provider. Coding: 99213-24 with a diagnosis unrelated to the surgery and documentation explicitly stating unrelatedness. Authority: Guidance on modifier -24 stresses strict "unrelated" criteria and the need for clear record support.

Across scenarios, the coding logic is consistent: either show low MDM via problem status/data/risk, or show total time 20-29 minutes with medically necessary day-of-service work. The modifiers (-25, -95, -24) do not "raise" the level; they explain billing context so the claim is processed correctly.