99213

Office or Other Outpatient Visit, Established Patient, Low MDM / 20-29 Minutes

CPT code 99213 represents an office or other outpatient visit for the evaluation and management (E/M) of an established patient. This service requires a medically appropriate history and/or examination and a **low level of medical decision making (MDM)**. When using total time on the date of the encounter for code selection, **20-29 minutes** of total time is spent on the date of the encounter. This visit typically involves managing a stable chronic illness, evaluating a new minor problem, or addressing an exacerbation of a chronic problem that is improving or stable. The MDM for a low level generally involves a limited number of diagnoses or management options, a limited amount of data to be reviewed and analyzed, and a low risk of morbidity from additional diagnostic testing or treatment.

Clinical Indications

  • Routine follow-up for a stable chronic condition (e.g., controlled hypertension, well-managed type 2 diabetes, stable asthma).
  • Evaluation and management of a new minor problem (e.g., acute uncomplicated cystitis, mild upper respiratory infection) in an established patient.
  • Follow-up for an acute problem that is resolving or stable (e.g., post-treatment review of bronchitis, follow-up on a sprain).
  • Medication review and adjustment for a stable condition.
  • Discussion of test results and formulation of a low-complexity management plan.

Procedure Steps

  1. Patient Encounter: Face-to-face or telehealth interaction with the established patient.
  2. History Taking: Obtain a medically appropriate history as relevant to the presenting problem.
  3. Examination: Perform a medically appropriate examination as relevant to the presenting problem.
  4. Medical Decision Making (MDM): Assess the number and complexity of problems addressed, the amount and/or complexity of data reviewed and analyzed, and the risk of complications and/or morbidity or mortality of patient management decisions, meeting the criteria for a low level MDM.
  5. Counseling and Coordination: Provide counseling and/or coordination of care with other healthcare professionals or agencies, as necessary.
  6. Documentation: Record the history, examination findings, assessment, plan of care, and total time spent (if time is used for code selection) in the patient's medical record.

Coding Guidelines

  • 2021 E/M Guidelines: Code selection for 99213 is based on either the level of Medical Decision Making (MDM) or the total time spent on the date of the encounter. History and physical examination are required but are no longer criteria for code selection, only for medical necessity and appropriateness.
  • Time-Based Coding: If time is used for code selection, document the total time spent by the physician or other qualified health care professional (QHP) on the date of the encounter. This includes both face-to-face and non-face-to-face time. For 99213, the total time must be 20-29 minutes.
  • MDM-Based Coding: If MDM is used, the encounter must meet the requirements for a low level of MDM. This generally involves a limited number of diagnoses or management options, a limited amount and/or complexity of data to be reviewed and analyzed, and a low risk of complications and/or morbidity or mortality of patient management.
  • Established Patient: This code is for established patients only. An established patient is one who has received professional services from the physician or QHP, or another physician/QHP of the exact same specialty and subspecialty in the same group practice, within the past three years.
  • Documentation: The medical record must clearly support the chosen E/M level, whether based on MDM or total time.
  • Modifiers: Appropriate modifiers (e.g., -25 for a significant, separately identifiable E/M service on the same day as a minor procedure) should be used when applicable.
  • Telehealth: May be reported for services furnished via telehealth when the content and time requirements are met.

Associated ICD-10 Codes