Evaluation & management · General
Established patient office or outpatient visit requiring 20–29 minutes of total time or low-complexity medical decision-making.
Verified May 8, 2026 · 5 sources ↓
- Medicare
- $95.19
- Total RVUs
- 2.85
- Global, days
- Region
- General
Documentation requirements
What must appear in the operative or office note to support the claim.
Source · Editorial brief grounded in 5 cited references ↓
- Total time in minutes documented, including non-face-to-face work performed on the date of service, if billing by time
- Medical decision-making level documented with problems addressed, data reviewed, and risk assessment if billing by MDM
- Established patient status confirmed — patient must have been seen by a provider in the same group/specialty within the past 3 years
- Assessment and plan specific to the presenting problem(s), not a generic template entry
- If modifier 25 is used, the note must clearly show the E&M service was separate and distinct from any procedure performed that day
- Diagnosis codes that support the complexity level billed — a single stable chronic condition typically aligns with low-complexity MDM
Applicable modifiers
Modifiers commonly billed with this code.
Source · AMA CPT modifier descriptors · CMS NCCI Policy Manual
What this code covers
Source · Editorial summary grounded in 5 cited references ↓
99213 is the go-to E&M code for established patient follow-up visits involving a stable chronic condition or a straightforward acute problem. Billing is supported by either total encounter time of 20–29 minutes (face-to-face plus same-day work such as ordering, reviewing results, and documentation) or by meeting the threshold for low-complexity medical decision-making. You don't need both — one qualifying element is sufficient under post-2021 E&M guidelines.
In orthopedic practice, 99213 fits post-op visits outside the global period, straightforward medication or DME follow-ups, and injury rechecks where the clinical picture is stable. When a procedure — injection, I&D, minor soft-tissue work — is also performed on the same visit, append modifier 25 to 99213 to establish that the E&M was a separate, significant service. Without modifier 25 in that scenario, expect a bundling denial.
Documentation must reflect the level you're billing. A note that lists vitals and a one-line assessment won't support 99213 if you're billing on MDM — the note needs to show the problems addressed, data reviewed, and risk of complications or treatment. Payers, including Medicare, audit coding patterns against specialty benchmarks, so a practice billing 99213 for every established visit invites scrutiny just as much as one that never uses it.
RVU & reimbursement
Component RVUs and Medicare national rate. Actual payment varies by GPCI locality.
Source · CMS Physician Fee Schedule, RVU26A · January 2026
| Work RVU | 1.3 |
| Practice expense RVU | 1.46 |
| Malpractice RVU | 0.09 |
| Total RVU | 2.85 |
| Medicare national rate | $95.19 |
| Global period | days |
Payment by site of service
Medicare pays different rates by setting. HOPD typically pays substantially more than ASC for the same procedure.
Source · CMS OPPS Addendum B·ASC HCPCS payment rates·2026
| Setting | Medicare rate (national) |
|---|---|
Office (PFS non-facility) Procedure performed in physician's office | $95.19 |
Common denial reasons
The recurring reasons claims for CPT 99213 get rejected.
Source · Editorial brief grounded in CMS NCCI edits, AAOS coding appeals, and cited references ↓
- Missing or insufficient documentation of total time when billing on a time basis — 'approximately 20 minutes' without specifics invites downcoding
- Modifier 25 absent when 99213 is billed same-day as a procedure, triggering automatic bundling denial
- Upcoding pattern flagged by payer when 99213 is billed for visits whose notes reflect only minimal complexity
- New patient billed as established — if no provider in the group has seen the patient in the past 3 years, use 99203 instead
- Time-based billing counting only face-to-face time rather than total encounter time, falling short of the 20-minute threshold
Frequently asked questions
Source · Generated from the editorial pipeline, verified against 5 cited references ↓
01Can I bill 99213 based on time alone, without documenting MDM?
02When does 99213 require modifier 25 in orthopedic practice?
03How does 99213 differ from 99212 and 99214?
04Does the 99213 global period affect billing during post-op care?
05Can 99213 be billed for telehealth visits?
06Is 99213 ever appropriate for a new patient?
Sources & references
Editorial content was developed using the following public sources. Last verified May 8, 2026.
- 01ama-assn.orghttps://www.ama-assn.org/practice-management/cpt/cpt-code-99213-established-patient-office-visit-20-29-minutes
- 02cms.govhttps://www.cms.gov/medicare/coding-billing/national-correct-coding-initiative-ncci-edits
- 03cms.govhttps://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=56006&ver=19
- 04cms.govhttps://www.cms.gov/files/document/2025nccimedicarepolicymanualcompletepdf.pdf
- 05CMS Physician Fee Schedule 2026
Mira AI Scribe
Mira's AI scribe captures total encounter time (including chart review, ordering, and post-visit documentation), the specific problem(s) addressed, MDM elements (data reviewed, risk level, number and complexity of problems), and any procedures performed the same day. That prevents the two most common 99213 denials: time underdocumented when billing by the clock, and a missing modifier 25 justification when a procedure runs concurrent with the E&M.
See how Mira captures CPT 99213 documentation