99213

Office or Outpatient Evaluation and Management of an Established Patient, Low Complexity

99213 is a mid-level Evaluation and Management (E/M) code used for established patients in an office or outpatient setting. An established patient is defined as one who has received professional services from the physician or another physician of the same specialty and subspecialty in the same group practice within the past three years. This code represents a low level of complexity, typically involving the management of a stable chronic condition or an acute, uncomplicated illness. Under the 2021 and subsequent 2023 CPT revisions for outpatient E/M services, the selection of 99213 is strictly based on either the level of Medical Decision Making (MDM) or the total time spent by the provider on the date of the encounter. For MDM, 99213 requires a 'Low' level of complexity. This level is met when the physician addresses two or more stable chronic illnesses, one stable chronic illness, one acute uncomplicated illness or injury, or one stable acute illness. The data component for low MDM involves minimal or limited review of records or tests, and the risk component involves a low risk of morbidity from additional diagnostic testing or treatment. Alternatively, if time is used for code selection, the provider must document 20 to 29 minutes of total time spent on the date of the encounter. This time includes both face-to-face and non-face-to-face work such as reviewing records, performing the exam, counseling the patient, ordering medications, and documenting the electronic health record. This code is widely used in primary care for routine follow-ups and management of minor acute problems.

Clinical Indications

  • Management of one stable chronic condition (e.g., controlled hypertension).
  • Management of two or more stable chronic conditions.
  • Treatment of an acute, uncomplicated illness (e.g., pharyngitis or cystitis).
  • Evaluation of a stable acute illness.
  • Follow-up for a minor injury (e.g., uncomplicated sprain).
  • Routine medication management and monitoring for stable conditions.
  • Counseling for a patient with well-controlled chronic symptoms.

Procedure Steps

  1. Review of the patient's medical record and previous encounter notes to prepare for the visit.
  2. Performance of a medically appropriate history, focusing on interval changes and current symptoms.
  3. Performance of a medically appropriate physical examination as determined by the provider.
  4. Assessment of the patient's current health status and response to existing therapeutic interventions.
  5. Review of relevant diagnostic test results (e.g., labs, imaging) or ordering of new tests.
  6. Selection of appropriate management options, including prescription refills or changes.
  7. Provision of patient education, counseling, or coordination of care with other healthcare professionals.
  8. Finalization of documentation in the electronic health record, including total time if billing based on time.

Coding Guidelines

  • Code only applies to established patients (seen within the last 3 years by the same specialty in the same group).
  • Selection is based on Low Level Medical Decision Making (MDM) or 20-29 minutes of total time.
  • History and examination must be performed as medically appropriate, but they do not determine the level of the code.
  • Total time includes both face-to-face time and non-face-to-face time spent by the provider on the date of encounter.
  • If a separate, identifiable procedure is performed (e.g., a joint injection), append modifier 25 to the 99213 code.
  • Cannot be billed if the patient is seen in an inpatient or observation setting; different codes apply.
  • Bundling: Includes all routine activities associated with the visit; specialized procedures are billed separately.

Associated ICD-10 Codes