99213

Office or Other Outpatient Visit for the Evaluation and Management of an Established Patient, Low Complexity Medical Decision Making

CPT code 99213 describes an office or other outpatient visit for the evaluation and management of an established patient that requires a low level of medical decision making (MDM) or 20-29 minutes of total time spent on the date of the encounter. This includes both face-to-face and non-face-to-face time. A low level of MDM typically involves the management of two or more self-limited or minor problems, one stable chronic illness, or one acute, uncomplicated illness or injury. The amount and/or complexity of data reviewed or analyzed is limited, and the risk of complications and/or morbidity or mortality of patient management is low.

Clinical Indications

  • Follow-up for a stable chronic illness (e.g., well-controlled hypertension, type 2 diabetes without new complications, stable asthma).
  • Evaluation of a new problem that is minor and self-limited or acute and uncomplicated (e.g., common cold, simple sprain, uncomplicated urinary tract infection).
  • Medication management and adjustment for an established, stable chronic condition.
  • Review of diagnostic test results for a stable condition with limited data analysis.
  • Routine follow-up for a patient recovering from an acute, uncomplicated illness or injury.

Procedure Steps

  1. Obtain a focused interval history from the patient regarding the presenting problem(s) and relevant system review.
  2. Perform a problem-focused or expanded problem-focused physical examination relevant to the presenting complaint.
  3. Review and analyze limited data, such as results of previously ordered diagnostic tests or external records.
  4. Perform medical decision making of low complexity, involving diagnosis and treatment plan formulation for a limited number of problems with low risk.
  5. Counseling and/or coordination of care with other providers, as appropriate, for the patient's condition.
  6. Order appropriate diagnostic tests, therapeutic interventions, or prescriptions.
  7. Document the history, physical exam findings, assessment, plan of care, and total time spent (if time is the dominant factor).

Coding Guidelines

  • Code 99213 is used for an established patient. An established patient is one who has received professional services from the physician or another physician of the exact same specialty and subspecialty in the same group practice within the past three years.
  • Coding for 99213 is based on either the level of medical decision making (MDM) or the total time spent on the date of the encounter (20-29 minutes).
  • To qualify for low MDM, at least two of the three MDM elements must be met: 1) Number and complexity of problems addressed: Minimal (e.g., 2+ self-limited/minor, 1 stable chronic, or 1 acute uncomplicated illness/injury). 2) Amount and/or complexity of data to be reviewed and analyzed: Limited. 3) Risk of complications and/or morbidity or mortality of patient management: Low.
  • When using time for coding, total time includes both face-to-face and non-face-to-face time personally spent by the physician or other qualified healthcare professional on the date of the encounter.
  • Documentation must clearly support the chosen level of service, whether by MDM criteria or total time spent. If time is used, the total time and a brief description of the activities performed must be documented.
  • Modifier 25 (Significant, separately identifiable E/M service by the same physician or other qualified health care professional on the same day of the procedure or other service) may be appended if a separately identifiable E/M service is performed on the same day as a minor procedure.

Associated ICD-10 Codes