99213 CPT Code: Complete Documentation Requirements & Compliance Guide
What is CPT Code 99213?
CPT code 99213 is one of the most frequently billed evaluation and management (E/M) codes in outpatient settings. It represents an established patient office visit requiring a medically appropriate history and/or examination and low-level medical decision making (MDM). With typical face-to-face time of 20–29 minutes, 99213 serves as the workhorse code for routine follow-up visits in primary care and specialty practices.
Understanding the 99213 CPT code documentation requirements is crucial for compliance, proper reimbursement, and avoiding audit risk. This comprehensive guide breaks down everything you need to know about billing 99213 correctly.
99213 CPT Code Description and Key Components
The official CPT code 99213 description states:
"Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter."
Key Requirements for 99213:
Patient Status: Established patient (seen within the past 3 years)
Setting: Office or other outpatient location
Medical Decision Making: Low complexity
Time Alternative: 20–29 minutes total time on date of service
Medical Decision Making (MDM) Requirements for 99213
Since the 2021 E/M guideline changes, medical decision making or total time determines the appropriate E/M level. For 99213, you need to meet low-level MDM, which requires meeting 2 of 3 elements:
1. Number and Complexity of Problems Addressed
Two or more self-limited or minor problems; OR
One stable chronic illness; OR
One acute, uncomplicated illness or injury
2. Amount and/or Complexity of Data Reviewed
Must meet the requirements of at least 1 of the 2 categories:
Category 1: Tests and documents (Any combination of 2 from):
Review of prior external note(s) from each unique source
Review of the result(s) of each unique test
Ordering of each unique test
Category 2: Assessment requiring an independent historian
3. Risk of Complications and/or Morbidity or Mortality
Low risk of morbidity from additional diagnostic testing or treatment. Examples include:
Over-the-counter drugs
Minor surgery with no identified risk factors
Physical therapy
Occupational therapy
IV fluids without additives
Common 99213 Documentation Mistakes to Avoid
Even experienced providers can make documentation errors that put 99213 claims at risk. Here are the most common pitfalls:
Insufficient Problem Documentation
Listing diagnoses without describing their current status
Not documenting whether chronic conditions are stable, worsening, or improving
Missing Data Review Documentation
Reviewing labs but not documenting which specific results were reviewed
Failing to document review of outside records
Copy-Paste Errors
Carrying forward outdated information from previous visits
Inconsistencies between different sections of the note
Time-Based Billing Errors
Not documenting total time when using time for code selection
Including time spent on separately billable procedures
99213 vs 99214: Understanding the Difference
The distinction between 99213 and 99214 often comes down to medical decision making complexity:
Element | 99213 (Low MDM) | 99214 (Moderate MDM) |
|---|---|---|
Problems Addressed | 1 stable chronic illness OR 2 minor problems | 1 or more chronic illnesses with exacerbation/progression OR 2+ stable chronic illnesses |
Data Reviewed | Limited (Category 1: 2 elements) | Moderate (Category 1: 3 elements OR Category 2: 1 element) |
Risk Level | Low | Moderate |
Time Alternative | 20–29 minutes | 30–39 minutes |
Best Practices for 99213 Documentation Compliance
1. Create a Consistent Documentation Template
Develop templates that prompt providers to document all required MDM elements:
Problem list with current status
Data reviewed section
Assessment and plan with risk discussion
2. Document Specific Details
Instead of "reviewed labs," write "reviewed CBC from 10/15/23 showing stable anemia"
Rather than "stable HTN," document "hypertension stable on current medications, BP 128/78 today"
3. Implement Regular Audits
Conduct periodic reviews of 99213 documentation to ensure:
MDM elements support the billed level
Documentation is complete and specific
Time is properly documented when used for code selection
4. Leverage Technology for Compliance
Modern compliance platforms can automatically review documentation to ensure it meets 99213 requirements. Tools like Brellium use AI to audit 100% of patient visits, flagging documentation gaps and providing real-time feedback to prevent claim denials and audit risk.
99213 Reimbursement and RVU Values
Understanding the financial impact of proper 99213 coding is essential:
Work RVUs: 1.3
Total RVUs: Approximately 2.2 (varies by geographic location)
Medicare Reimbursement: Approximately $93–$95 (2024 rates, location-dependent)
Given that 99213 is one of the most frequently billed E/M codes, even small improvements in documentation compliance can significantly impact practice revenue.
How Brellium Helps Ensure 99213 Compliance
Brellium's AI-powered clinical compliance platform automatically reviews every patient encounter to ensure proper documentation for codes like 99213. The platform:
Identifies Documentation Gaps: Flags missing MDM elements before claims submission
Prevents Overcoding/Undercoding: Ensures documentation supports the billed level
Provides Real-Time Feedback: Alerts providers to fix issues while details are fresh
Reduces Audit Risk: Catches common errors like copy-paste issues and missing time documentation
By automating the compliance review process, Brellium helps practices maintain accurate 99213 documentation while reducing the administrative burden on staff.
Frequently Asked Questions About CPT Code 99213
Can I bill 99213 for a telehealth visit?
Yes, 99213 can be billed for telehealth visits when the service meets all documentation requirements. The same MDM or time criteria apply whether the visit is in-person or virtual.
What if my visit time is exactly 20 minutes?
A visit lasting exactly 20 minutes meets the minimum time requirement for 99213 when using time for code selection. Document the total time spent on the date of encounter.
How often can I bill 99213 for the same patient?
There's no specific frequency limit for 99213. Bill it whenever medically necessary and documentation supports the service level. However, excessive frequency without clear medical necessity may trigger payer audits.
Do I need to document both history and exam for 99213?
Under current guidelines, you need a "medically appropriate" history and/or examination. The extent depends on clinical judgment and the presenting problem—not prescribed documentation elements.
Conclusion: Mastering 99213 Documentation
Proper documentation for CPT code 99213 requires understanding MDM requirements, avoiding common pitfalls, and maintaining consistent documentation practices. While the 2021 E/M changes simplified some aspects of coding, they also introduced new complexities in MDM documentation.
Success with 99213 coding comes from:
Clear, specific documentation of problems addressed
Detailed recording of data reviewed
Appropriate risk assessment documentation
Consistent application of guidelines across all providers
By following these guidelines and leveraging technology solutions for compliance monitoring, practices can ensure accurate 99213 billing while focusing on what matters most—providing quality patient care.
