The CPT Code 99213 is used for established patient office visits that need moderate medical decision-making. Think of it as a middle-level visit. Not too simple, not too complex.
Are you confused about CPT 99213? You’re not alone. This code trips up many healthcare providers. In this guide, we explain what CPT 99213 means, how it works in billing, its reimbursement rules in 2025, and how it compares with other E/M codes.
What Is CPT 99213?
CPT 99213 belongs to the evaluation and management billing family. It’s part of the E/M codes group. This specific code covers office visits for patients you’ve seen before.
Think of it as a Level 3 E/M visit. It sits between the simpler 99212 and the more complex 99214.
- You use CPT 99213 when a patient returns to the clinic.
- The visit involves a routine follow-up or check-up.
- The doctor provides care, updates treatment, and may review test results.
The office visit must involve moderate complexity issues. Maybe your patient has diabetes that needs adjusting. Or they have high blood pressure with new symptoms. These situations often fit the 99213 billing criteria.
CPT 99213 Code Usage in Daily Practice
CPT Code 99213 is common in outpatient visits. It applies to established patients who need a moderate level of care. Below are examples where this code fits:
Example 1
Chronic Disease Follow-Up
A patient with type 2 diabetes comes for a routine check. The provider reviews blood sugar logs, adjusts medication, and gives diet advice. This is a perfect 99213 scenario.
Example 2
Orthopedic Pain Management
A patient with knee osteoarthritis reports ongoing pain. The provider examines the joint, reviews imaging, and modifies the treatment plan. That fits CPT 99213 billing.
Example 3
Post-Surgical Follow-Up
An orthopedic surgeon sees a patient two weeks after surgery. The exam checks wound healing and mobility. The visit involves moderate complexity decision-making, making 99213 the right code.
Example 4
Asthma Check-Up
A child with mild persistent asthma comes in for follow-up. The provider checks inhaler use, reviews symptom frequency, and updates the action plan. This is a Level 3 E/M visit (99213).
Example 5
Back Pain Assessment
An established patient complains of lower back pain. The provider checks mobility, orders an X-ray, and recommends therapy. This matches 99213 documentation requirements.
Example 6
Dermatology Case – Rash Evaluation
A patient returns for a recurring skin rash. The provider reviews past treatment, checks new symptoms, and prescribes a cream. This fits CPT 99213 time guidelines.
Time Guidelines for CPT 99213
Let’s talk about CPT 99213 time guidelines. The rules changed recently in 2025. Now you can bill based on time alone. No more complex point systems!
If you spend 20-29 minutes with the patient, you can use CPT 99213. This includes time before, during, and after the visit. Pretty straightforward, right?
Time includes:
- Reviewing records
- Talking with the patient
- Writing notes
- Coordinating care
But remember, you can also bill based on medical decision-making. Choose whichever method works better for your visit.
Documentation Requirements for CPT 99213
Billing CPT 99213 means your notes must prove the level of service. In 2025, documentation is tied to:
Medical decision-making (MDM).
- Must be low to moderate complexity.
- Two or more stable conditions may count.
Or time spent with the patient.
- Providers may bill 99213 if the visit time fits CPT 99213 time guidelines.
Documentation checklist:
- Chief complaint.
- History of present illness.
- Review of systems (if needed).
- Exam notes.
- Treatment plan.
- Risks and decisions made.
Tip: Proper documentation for CPT 99213 reduces claim denials and ensures compliance.
CPT 99213 vs CPT 99214: Know the Difference
Many healthcare providers confuse these two codes. Here’s a clear comparison:
| Feature | CPT 99213 | CPT 99214 |
|---|---|---|
| Patient type | Established | Established |
| Complexity | Low to moderate | Moderate to high |
| Time | 20–29 min | 30–39 min |
| Example visit | Diabetes follow-up, minor joint pain | Complex condition with multiple tests, medication changes |
CPT 99213 involves moderate complexity. CPT 99214 requires high complexity. The difference matters for reimbursement.
99213 characteristics:
- Moderate medical decision-making
- 20-29 minutes typical time
- Lower reimbursement rate
CPT 99214 characteristics:
- High medical decision-making
- 30-39 minutes typical time
- Higher reimbursement rate
CPT 99213 Reimbursement Rate in 2025
CPT 99213 reimbursement varies by location and payer. Medicare rates differ from private insurance. Geography also affects payment amounts. As a provider, you should look closely at the reimbursement rates.
In 2025, typical Medicare reimbursement ranges from $90-120. Private insurance often pays more. Check your local rates for accuracy.
Factors affecting reimbursement rate for office visit (CPT 99213):
- Geographic location
- Insurance type
- Contract negotiations
- Modifier usage
If you want higher reimbursement, you will require proper coding. Don’t leave money on the table.
Modifiers Used with CPT 99213
Sometimes, while billing for office visit, you will need to use modifiers. These modifiers are commonly used with CPT 99213.
- Modifier 25: When a significant, separately identifiable E/M service is provided along with a procedure.
- Modifier 95: If the visit is done via telehealth.
- Modifier 24: When the visit is unrelated to a recent surgery.
Using correct modifiers along with 99213 to prevents claim denials.
CPT 99213 Billing Mistakes to Avoid
As we discussed billing for code 99213 can be sometimes tough due to its complex structure. Here are some common mistakes providers often do, but you can avoid them reading this simple guide and lessen your denial rate.
Wrong Patient Type
CPT 99213 is for established patients only. New patients need different CPT codes. This mistake can cause you scratch your head and will lead to automatic denials.
Improper Documentation
Skimpy notes don’t support your code choice. Always document enough to justify CPT 99213 billing decisions.
Time Miscalculation
Don’t guess at time spent. Track it accurately. Wrong time documentation causes problems while billing the code 99213.
Complexity Misjudgment
Not every visit qualifies for CPT 99213. Some are simpler (CPT 99212). Others are more complex (CPT 99214). Choose carefully.
Role of CPT 99213 in Orthopedic Billing
In orthopedic practices, CPT 99213 is one of the most used codes. It helps orthopedic providers bill for follow-up visits and moderate care encounters with patients who already have a history with the clinic. Since orthopedic care often involves long-term treatment plans, this code becomes an essential part of orthopedic medical billing.
Here’s how CPT 99213 plays a role in orthopedic billing:
Post-Injury Check-Ups
Many patients return after a fracture, sprain, or dislocation. During follow-up, the provider examines healing progress, reviews imaging results, and may adjust physical activity advice. These visits are perfect for 99213 billing.
Post-Surgical Follow-Ups
Orthopedic surgeries like ACL repair or hip replacement require multiple check-ins. A provider might review wound healing, assess mobility, and answer questions. Since these visits are moderate in complexity, they qualify for CPT 99213 reimbursements.
Chronic Joint Pain Management
Conditions like osteoarthritis or chronic back pain need regular monitoring. The provider checks pain levels, examines joint function, and changes medication or therapy if needed. These routine but important visits are billed with CPT 99213.
Imaging Review and Treatment Planning
An established patient may bring updated X-rays or MRIs. The provider reviews the scans, compares with past images, and adjusts the care plan. This falls under 99213 documentation requirements.
Brace, Cast, or Splint Adjustments
Orthopedic patients often return for adjustments of braces, casts, or splints. If the visit involves evaluation, medical decision-making, and patient counseling, 99213 coding applies.
Sports Injury Follow-Ups
Young athletes with shoulder strains, ligament injuries, or knee problems often need follow-up checks. These moderate visits, which don’t involve high-risk decision-making, usually match Level 3 E/M (99213).
Therapy Progress Evaluations
Patients undergoing physical or occupational therapy are sometimes sent back to the orthopedic specialist for progress checks. Reviewing therapy outcomes and adjusting the plan is another valid case for 99213 usage.
Why this matters for orthopedic billing:
- CPT 99213 prevents underbilling by capturing the right level of care.
- It supports accurate reimbursement from Medicare and private payers.
- Correct usage helps avoid claim denials and compliance risks.
- It plays a huge role in keeping the revenue cycle smooth for orthopedic practices.
How CPT 99213 Impacts Revenue Cycle Management
CPT 99213 might look like a simple code, but it has a big role in the revenue cycle management (RCM) of healthcare practices, especially in orthopedics.
Here’s how it impacts your RCM:
High Volume = High Financial Impact
99213 is billed millions of times each year across the U.S. For an orthopedic clinic, it can make up a large share of all outpatient visits.
Reduces Claim Denials When Used Properly
Incorrect use of 99213 billing (such as using it for a new patient) leads to claim rejections. Every denial means:
- Extra staff time for resubmission
- Delay in cash flow
- Risk of permanent revenue loss if not corrected on time
- Accurate documentation = clean claims = faster payment.
Direct Link to Reimbursement
Average CPT 99213 reimbursement (Medicare 2025 rates) is around $90–$100, depending on the state and payer. For a practice that sees 20–30 patients daily, accurate coding of 99213 can account for thousands of dollars in revenue every week.
Impacts Patient Satisfaction
Believe it or not, RCM is tied to patient experience. Clean billing avoids confusing patient statements, unexpected denials, or balance bills. Patients trust practices that handle billing transparently.
Role in Value-Based Care
Many payers now track the frequency and accuracy of E/M codes like 99213. Correct use shows that a practice is managing patients properly without overbilling. This helps in building payer trust and supports participation in value-based contracts.
CPT 99213 is more than just a billing code—it’s a financial backbone. When used correctly, it speeds up payments, cuts down denials, boosts compliance, and supports sustainable practice growth.
Why Work with a Medical Billing Partner?
Managing codes like CPT 99213 may seem simple, but it takes time, accuracy, and focus. For busy providers like you, outsourcing billing is often the smarter move.
Key benefits include:
- Less paperwork stress
- More time for patient care
- Higher and faster collections
- Stronger compliance with payer rules
At Ortho Billing Expert, we support providers in California and Florida with reliable orthopedic billing and coding services so you can focus on healing, not paperwork.
Conclusion
CPT 99213 is a valuable code for healthcare providers. When used correctly, it brings full reimbursement. It also supports quality patient care.
Remember the key points:
- Use CPT 99213 for established patients only
- Document moderate complexity or 20-29 minutes
- Avoid common coding mistakes
- Stay current with payer regulation changes
- Invest in staff training
If you are a healthcare provider, solo practitioner, or physician looking for reliable billing support, we can help. just contact us.
FAQs
I think there are some questions in your mind. You can clearly ask. However, if the questions are these, then you can have simple answers. Here they are:
What is CPT code 99213 description?
CPT code 99213 description refers to an office or outpatient visit for an established patient. It usually involves low to moderate complexity evaluation and management.
What is CPT code 99213?
CPT code 99213 is used when a provider sees an established patient for a routine check-up, follow-up, or minor health concern that needs moderate medical decision-making.
What is the difference between CPT code 99213 and 99214?
The main difference is complexity and time. CPT code 99213 is for low to moderate issues, while CPT code 99214 involves higher complexity and longer visits.
What is CPT code 99213 modifier 25?
Modifier 25 is added to CPT code 99213 when a significant, separate evaluation is performed on the same day as another procedure.
What is CPT code 99213 modifier 95?
Modifier 95 is used with CPT code 99213 when the visit is done through telehealth instead of in-person.
What is CPT code 99213 cost?
The cost of CPT code 99213 depends on payer rules, but on average it ranges from $75 to $150. Medicare and private insurance may set different reimbursement rates.