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You have a visit to code. You need the right level. You don’t have time for a tutorial.
Here’s your answer: if the visit was 20 to 29 minutes OR involved low MDM, it’s 99213. If it went beyond either threshold, check 99214.
Not sure which applies? Work through the decision tool below. Grab the documentation template that fits. Done in five minutes. If a visit doesn’t fit any standard scenario, our coding support team handles it same day.
99213 in 30 Seconds
You need enough context to confirm you’re in the right place. Here it is.
CPT code 99213 is an office or outpatient visit for an established patient requiring low complexity medical decision making, or 20 to 29 minutes of total time on the date of the encounter.
That’s the code. Use either the time pathway or the MDM pathway. Whichever your documentation supports.
2026 Medicare rate (non-facility): approximately $91.85
If your visit fits either threshold, bill 99213. If it goes beyond both, check 99214. Let’s find out which applies.
Is This Visit 99213? Answer in 60 Seconds
Work through these steps in order. Stop when you have your answer.
Step 1: Confirm the Patient Is Established
Has this patient been seen by any provider of the same specialty in this group within the past three years? If no, stop here. Use new patient codes 99202 to 99205 instead. If yes, keep going.
Step 2: Use Time OR MDM
| Pathway | 99212 | 99213 | 99214 | 99215 |
|---|---|---|---|---|
| Time (total minutes on date) | 10 to 19 min | 20 to 29 min | 30 to 39 min | 40 to 54 min |
| MDM Level | Straightforward | Low | Moderate | High |
| Problems addressed | 1 minor, stable | 1 stable chronic OR 1 acute simple | 2+ chronic OR 1 worsening | Severe or life-threatening |
Choose one pathway per visit. If time says 99213 but MDM says 99214, bill 99214. Pick the pathway your documentation actually supports, not the pathway that’s easier to document.
Low MDM in Plain Terms
Low MDM means one of the following. One stable chronic illness you’re managing. Or one uncomplicated acute illness. A prescription refill for the stable condition qualifies. Reviewing a lab result or two is fine. The risk is low: no high-risk prescriptions, no major procedures, nothing uncertain about the diagnosis or treatment.
The 80% rule: one problem, stable = 99213. Two problems or anything worsening = check 99214. That covers most decisions at this boundary.
Find Your Visit, Get Your Code
Find the scenario that matches your visit. The code and documentation template are right there.
Scenario A: Stable Chronic Disease Follow-Up
The visit: established patient with one stable chronic condition. Current treatment continues. No changes needed. The patient is at goal.
The code: 99213. Time is usually 20 to 25 minutes. MDM is low: one stable chronic illness.
Copy-paste documentation:
ASSESSMENT/PLAN:
1. [CONDITION] – stable, at goal. Continue current regimen.
– Reviewed [home monitoring/labs/symptoms] – within target
– No medication changes
– Follow-up [timeframe]
TIME: Total time on date of service: [XX] minutes
Activities: chart review, examination, counseling, documentation
Scenario B: Minor Acute Problem
The visit: established patient with an acute uncomplicated illness. URI, UTI, minor rash, or similar. Straightforward workup with a clear treatment plan.
The code: 99213. Time is usually 18 to 25 minutes. MDM is low: one acute uncomplicated problem.
Copy-paste documentation:
ASSESSMENT/PLAN:
1. [ACUTE CONDITION] – uncomplicated presentation
– Symptoms: [brief description]
– Exam findings: [key findings]
– Treatment: [OTC/Rx – specify drug, dose, duration]
– Return precautions given
TIME: Total time on date of service: [XX] minutes
Scenario C: Medication Refill With Brief Review
The visit: established patient needing a refill. Brief clinical review, no changes, condition stable. Prescription management is present, which is enough for low MDM even without active changes.
The code: 99213. Time is usually 15 to 22 minutes. MDM is low: prescription management at low risk.
Copy-paste documentation:
ASSESSMENT/PLAN:
1. [CONDITION] – stable on current medication
– Tolerating [medication] without adverse effects
– Refill provided: [medication, dose, quantity, days supply]
– No changes to regimen
– Follow-up [timeframe]
TIME: Total time on date of service: [XX] minutes
Scenario D: This Might Be 99214 Instead
Check this before you submit. These are the situations where 99213 is the wrong code.
Upgrade to 99214 if any of these apply:
- Managing two or more chronic conditions in the same visit
- One condition is worsening or not at goal
- A new problem needs workup before you can treat it
- Prescription drug management with significant risk
- Total visit time was 30 minutes or more
If any of those fit, bill 99214. Not 99213.
99213 Documentation Templates: Ready to Use
Three templates. Pick the one that fits how you’re selecting the code. Fill in the brackets. Done.
Template 1: Time-Based 99213
TOTAL TIME: [XX] minutes (must be between 20 and 29)
TIME BREAKDOWN (list your activities):
– Chart review: [X] min
– Examination: [X] min
– Counseling/patient education: [X] min
– Care coordination: [X] min
– Documentation: [X] min
CHIEF COMPLAINT: [Patient’s reason for visit]
ASSESSMENT/PLAN:
1. [Diagnosis] – [stable/improving/etc.]
– [Treatment plan]
– [Follow-up timeframe]
Template 2: MDM-Based 99213
CHIEF COMPLAINT: [Patient’s reason for visit]
PROBLEMS ADDRESSED:
1. [Condition] – [stable/controlled/at goal]
DATA REVIEWED:
– [Lab/imaging/records reviewed – be specific]
ASSESSMENT/PLAN:
1. [Diagnosis] – [Status]
– Treatment: [OTC/continued Rx – name drug and dose]
– Risk: Low (prescription management OR minor treatment)
– Follow-up: [timeframe]
MDM COMPLEXITY: LOW
Basis: 1 stable chronic illness OR 1 acute uncomplicated problem
Template 3: Complete 99213 Note
CHIEF COMPLAINT: [Reason for visit]
HPI: [Brief relevant history – 2 to 3 sentences]
EXAM: [Medically appropriate findings relevant to complaint]
DATA REVIEWED: [Specify: which labs, which records, which imaging]
ASSESSMENT/PLAN:
1. [Diagnosis] – [stable/at goal/improving]
– Plan: [Continue current treatment OR minor adjustment]
– Risk: Low
– Follow-up: [Timeframe]
TOTAL TIME: [XX] minutes
Activities: chart review, exam, counseling, care coordination, documentation
CODE JUSTIFICATION: 99213 – Low MDM / 20 to 29 minutes
99213 or 99214? Quick Comparison Card
Use this when you’re at the boundary between the two. Most decisions come down to problem count.
| Factor | 99213 | 99214 |
|---|---|---|
| Time range | 20 to 29 minutes | 30 to 39 minutes |
| MDM Level | Low | Moderate |
| Problems addressed | 1 stable chronic OR 1 acute simple | 2+ stable chronic OR 1 worsening |
| Data review | Limited (some tests or records) | Moderate (more complex data work) |
| Risk | Low (prescription management OK) | Moderate (Rx with significant risk) |
| 2026 Medicare rate (non-facility) | ~$91.85 | ~$131.45 |
| Revenue difference per visit | Baseline | +$39.60 |
The fastest decision rule: count your problems. One problem, stable = 99213. Two or more problems, or one worsening = 99214. That covers 80% of decisions at this boundary.
If you’re regularly coding 99213 when the visit actually supports 99214, those $39.60 differences compound quickly. Our denial management services team can run a quick E/M pattern review.
99213 Modifiers: When You Need Them
Three modifiers come up regularly with 99213. Here’s when each one applies.
| Situation | Modifier | Example |
|---|---|---|
| E/M and procedure on the same date | 25 | 99213-25 and 11200 (skin tag removal) |
| Telehealth visit (audio-video) | 95 | 99213-95 |
| Telehealth (some commercial payers) | GT | 99213-GT |
Modifier 25: Copy-Paste Justification Language
Add this language to the note when billing 99213 alongside a same-day procedure:
The E/M service provided today was significant and separately identifiable from
[procedure name]. The evaluation addressed [condition], which required independent
medical decision-making beyond the [procedure] performed.
Modifier 25 rule: only use this when the E/M is genuinely separate from the procedure. If you can’t explain why in one sentence, don’t bill it. The documentation has to show two distinct clinical purposes.
2026 Reimbursement: What You’ll Get Paid
The numbers, without the math lesson.
| Payer Type | 2026 CPT 99213 Rate |
|---|---|
| Medicare (non-facility, office) | ~$91.85 |
| Medicare (facility, hospital outpatient) | ~$65.80 |
| Work RVU | 1.30 |
| UnitedHealthcare (typical range) | $87 to $105 |
| BCBS (typical range) | $95 to $115 |
| Aetna (typical range) | $90 to $108 |
| Cigna (typical range) | $88 to $102 |
Rates vary by locality. Use the CMS Physician Fee Schedule Look-Up Tool to verify your exact rate. Actual collections depend on your payer contracts and geographic cost index.
5 Mistakes That Get 99213 Denied (And Quick Fixes)
Most 99213 denials trace back to five documentation gaps. Each one takes under two minutes to fix before submission.
| Mistake | Fix | Time to Fix |
|---|---|---|
| No chief complaint in the note | Add CC: [reason for visit] | 30 seconds |
| Vague time: ‘spent time with patient’ | Add exact minutes plus activities performed | 1 minute |
| Missing problem status | Add ‘stable’ or ‘worsening’ after the diagnosis | 30 seconds |
| Data documentation missing | Add ‘Reviewed [specific test/record/result]’ | 1 minute |
| Wrong patient status used | Verify: seen by same specialty group within 3 years = established | 1 minute |
Pre-Submission Checklist
Run through these five checks before every 99213 claim goes out. All five answers should be yes.
- Chief complaint documented in the note?
- Time (20 to 29 min) OR low MDM clearly stated?
- Problem status included: stable, improving, or worsening?
- Data reviewed specified (not just ‘reviewed chart’)?
- Patient is established: seen by same specialty group within past 3 years?
Five checks. Two minutes. Those five gaps cause the majority of preventable 99213 denials.
99213 by Specialty: Quick Reference
Use these as pocket references for the three most common billing contexts.
Primary Care
Typical 99213 visits:
- Single stable chronic condition (HTN, DM at goal)
- Medication refill, no changes needed
- Minor acute illness: URI, sinusitis, mild UTI
Upgrade to 99214 if:
- Managing two or more chronic conditions
- A1C, blood pressure, or other metric not at goal
- Medication adjustment required
Urgent Care
Typical 99213 visits:
- URI, sinusitis, or pharyngitis
- Simple UTI with straightforward treatment
- Minor injury with no imaging needed
Upgrade to 99214 if:
- Uncertain diagnosis requiring workup before treatment
- Imaging or significant testing ordered
- Multiple problems addressed in the same encounter
Telehealth
Billable: yes, for audio-video encounters.
Modifier required: Modifier 95 (or GT for some commercial payers).
POS codes: use POS 10 when the patient is at home, POS 02 for other locations. POS 10 earns the higher non-facility rate.
Documentation to add: “Services provided via real-time interactive audio/video technology.”
Audio-only visits: use codes 99441 to 99443 instead of 99213.
ClaimMax’s telehealth medical billing services team handles 99213 telehealth claims across all payers, including modifier and POS code verification on every submission.
When to Stop and Get Help
This guide covers the straightforward decisions. Some visits don’t have a quick answer. Here’s when to stop coding on your own.
Escalate if any of these apply:
- You’re spending more than five minutes deciding the code
- The visit doesn’t fit any standard scenario
- Same documentation keeps coming back denied
- You’re unsure whether it’s 99213, 99214, or 99215
- A payer is rejecting claims despite what looks like correct coding
- You need to code 50 or more visits and don’t have bandwidth
These aren’t coding questions. They’re workflow problems. Getting help is faster than guessing.
ClaimMax RCM provides same-day coding support for practices that need answers fast. We don’t explain the code; we code the visit. Contact our team to stop guessing on complex claims.
Quick Answers: 99213 Coding
How do I know if it’s 99213 or 99214?
Count your problems. One stable chronic condition or one simple acute problem equals 99213. Two or more problems, or one that’s worsening, equals 99214. Check time as a backup: 20 to 29 minutes is 99213, 30 to 39 minutes is 99214.
What’s the fastest way to document 99213?
Use time-based documentation. Write ‘Total time: 24 minutes’ and list your activities: chart review, exam, counseling, documentation, care coordination. Takes under 60 seconds. That’s all that’s required when using the time pathway.
Can I bill 99213 for telehealth?
Yes. Add Modifier 95. Document that services were provided via real-time interactive audio and video technology. Time and MDM thresholds are identical to in-person visits. Use POS 10 when the patient is at home to ensure the claim processes at the non-facility rate.
When do I add Modifier 25?
When you’re billing 99213 and a procedure on the same date. The E/M must be separately identifiable from the procedure. Your note needs one sentence explaining that the evaluation addressed a different clinical purpose than the procedure. If you can’t write that sentence, don’t bill both.
What gets 99213 denied most often?
Missing chief complaint and vague time documentation. Always include ‘CC: [reason for visit]’ and ‘Total time: [X] minutes’ with a list of activities. Those two gaps cause the majority of preventable 99213 denials.
Is 99213 the same for Medicare and commercial payers?
Same code, same clinical requirements. Different payment. Medicare pays approximately $91.85 in non-facility settings. Commercial payers typically range from $87 to $115 depending on contract terms. Verify your exact rate with each payer, since rates vary by region and contract.
How many times can I bill 99213 for the same patient?
As many times as medically necessary. There’s no frequency limit under Medicare or most commercial payers. Each visit must be documented separately and independently meet the time or MDM threshold. The patient just needs to be established, meaning seen within the past three years.
What’s the work RVU for 99213?
1.30 work RVUs. At a $50 per wRVU benchmark, that’s $65 in production value per visit. Correct coding here ensures accurate productivity tracking, which matters in most physician compensation models that use RVU-based calculations.
Code It. Document It. Bill It. Done.
99213 coding doesn’t have to take more than five minutes. Confirm the visit fits 20 to 29 minutes or low MDM, grab the template that matches your scenario, fill in the brackets, submit.
No tutorials. No deep dives. Just the right code, the right documentation, and the right payment.
If you’re still working through it after five minutes, something specific is blocking you. That’s a workflow problem, not a knowledge gap. Getting it fixed is faster than working around it permanently.
When coding decisions slow you down, ClaimMax RCM speeds them up. We provide same-day coding support, ready-to-use templates, and direct answers. Our AR follow-up team also works denied E/M claims so incorrectly denied 99213 visits don’t sit in your aging report.
Last Updated: 2026
Reviewed by: Coding Efficiency Specialist, ClaimMax RCM. Reflects 2026 Medicare PFS Final Rule. Templates verified against AMA CPT 2026 guidelines.
