CPT Code 99213 With Examples and What Medicare Actually Pays for It

Search for 99213 and most of what you find gives you a definition and a dollar figure.

The definition is usually right. The dollar figure is almost always wrong, because there isn't one. What Medicare pays for a 99213 depends on where you practice, and every article quoting a single national number is either out of date or correct for exactly one part of the country.

Here is what the code is, how the payment is actually calculated, where the line sits against 99214, why claims get denied, and a documentation template with two worked examples.

Key Takeaway: Medicare does not publish one price for 99213. The fee schedule amount for a participating supplier is calculated as the relative value units (RVUs) for the service, multiplied by the geographic adjustment factor (GAF) for your fee schedule area, multiplied by the conversion factor (CF) [1]. RVUs are established separately for physician work, practice expense and malpractice insurance [2], and a non-participating supplier is paid 95 percent of the participating amount [1]. The only current figure for your locality comes from the Centers for Medicare & Medicaid Services (CMS) Physician Fee Schedule Look-Up Tool [3]. CPT code 99213 itself is the office or other outpatient visit for an established patient at a low level of medical decision making, or 20 to 29 minutes of total time on the date of the encounter [4]. Sully.ai drafts the note with the detail that supports the level you actually delivered.

What CPT Code 99213 Is

It is the office or other outpatient visit for an established patient, at a low level of medical decision making, or 20 to 29 minutes of total time on the date of the encounter [4].

It is also the most frequently reported office visit code in American medicine, which matters more than it sounds and is covered further down.

Established Patient, and Why That Word Decides the Code Set

Before any question about documentation, there is a question about which code set applies at all.

An established patient is one who has received professional services from you, or from another physician of the same specialty and subspecialty in the same group practice, within the past three years. Anyone else is a new patient, and new patients use the 99202 to 99205 range instead.

Get this wrong and the code is wrong regardless of how well the visit is documented. It is also one of the more common denial reasons, which is why it sits first here.

The Two Routes to 99213

There are two ways to arrive at this level, and you only need one of them.

Time. Twenty to 29 minutes of total time on the date of the encounter. Total time includes the non-face-to-face work you personally do that day: reviewing records beforehand, ordering, documenting, communicating results.

Medical decision making. A low level, which under the framework in place since 2021 means meeting or exceeding two of the three elements at low: problems addressed, data reviewed, and risk.

You pick whichever route the visit actually satisfies. The full decision making grid, including where moderate begins, is covered in the 99214 article rather than repeated here.

What 99213 Actually Pays

There Is No National Number, and Here Is Why

This is the question the search results say people most want answered, and it is the one nobody answers honestly.

The regulation sets a formula rather than a price. Under 42 CFR 414.20, the fee schedule amount for a participating supplier is computed as the product of three things [1]:

• The RVUs for the service

• The GAF for the fee schedule area

• The CF

Two of those three change. The conversion factor is set annually and moves most years. The geographic adjustment factor is different in Manhattan than in rural Nebraska, by design, because the cost of running a practice differs.

So a page telling you "99213 pays $X" is telling you what it paid in one place in one year. That is why this article does not give you a number, and why the last section tells you how to get your own in two minutes.

The Three Kinds of RVU

CMS establishes RVUs for three separate components: physician work, practice expense, and malpractice insurance [2].

Physician work RVUs are set on a relative scale, where the work involved in one service is rated against the work involved in others [2]. That is what "relative" means in the name: the scale compares services to each other rather than to any external cost.

The practice expense component is the one that produces a result people find surprising. The same code pays differently in a facility than in an office, because when you provide the service in a hospital outpatient department the facility carries the overhead, so the practice expense RVU is lower. Same work, same code, different payment, depending on where the visit happened.

The 95 Percent Rule Most Practices Forget

One line of the same regulation, easy to miss:

The fee schedule amount for a non-participating supplier for a physician service is 95 percent of the participating amount [1].

If your practice has not enrolled as participating, every 99213 you bill is worth five percent less before anything else is considered. Across a full year of the most commonly billed office visit code in medicine, that is not a rounding error.

How to Get Your Own Number in Two Minutes

Use the CMS Physician Fee Schedule Look-Up Tool [3]. Four choices and you have the real figure:

1. Select the year you are billing for

2. Enter 99213

3. Select your Medicare Administrative Contractor (MAC) locality

4. Choose facility or non-facility

One caveat worth stating. That gives you the Medicare amount. Commercial payers set their own rates, frequently as a percentage of the Medicare schedule, sometimes well above or below it. Treat the Medicare figure as your reference point rather than your full picture.

99213 or 99214

The most-asked question on this code, and it deserves a real answer rather than two definitions placed side by side.

Where the Line Falls

In practice, two things move a visit from 99213 to 99214 more often than anything else.

A second stable chronic illness. One stable chronic problem is low. Two is moderate. That is frequently the entire difference, and it is frequently already true of the patient in front of you.

Prescription drug management. Managing a prescription is moderate risk on its own. Adjusting a dose, starting something new, or making a considered decision to continue and monitor all count. Writing a refill without any of that thinking does not.

The Undercoding Problem

Here is the part no competing page will tell you, and it needs saying carefully.

99213 is the default. It gets chosen at the end of a long clinic, on visits that would have supported 99214, because it feels invisible. Nobody audits a 99213.

That instinct is understandable, and it has a cost that is not only financial.

A record that understates complexity is a worse record. The note is read later by a colleague covering your patient, by a risk adjustment process, by a utilization reviewer, by an insurer assessing a claim. A chart that consistently says "low complexity" about a patient with three chronic conditions is inaccurate, and that inaccuracy travels.

To be completely clear: this is not an argument for upcoding. The correct code is the one the work supports, and coding above that is fraud. The argument is that coding below what the work supports is also a documentation failure, and it is the far more common one.

Why a 99213 Gets Denied

The patient was not established. No professional service from you, or from a same-specialty colleague in your group, in the past three years. Bill the new patient code instead.

Neither route is evidenced. The note does not record total time on the date of the encounter, and it does not establish two of three decision making elements at low. Without either, nothing supports the level.

The visit was bundled into a same-day procedure. Where a separately identifiable evaluation and management service was provided on the same day as a procedure, it needs the appropriate modifier appended. Without it, payers bundle the visit into the procedure.

The diagnosis does not support medical necessity. The code can be perfectly documented and still be denied if the diagnosis submitted does not justify a visit at that level.

The 99213 Documentation Template

One block, complete as written. Paste it straight into a chart, or start from the progress note template and add the two lines below that carry the level.

OFFICE VISIT, ESTABLISHED PATIENT

• Patient, date of service: (and the rendering clinician)

• Established patient confirmation: (date of the most recent prior visit with you or a same-specialty colleague in the group)

• Chief complaint: "(in the patient's words)"

• History relevant to today: (what has changed since last visit, not a recitation of the whole record)

• Examination: (findings relevant to the problems being addressed today, with values)

• Problems addressed today: (each one named, with its status: stable, worsening, new)

• Data reviewed: (labs, imaging, notes from other clinicians, or "none" if none)

• Risk of management selected: (what you decided, and what the risk of that decision is)

• Route used: (time, or medical decision making; state which)

• If time: (total time on the date of the encounter, and what it comprised)

• Assessment and plan, per problem: (each problem gets its own assessment and its own plan, the same structure a SOAP note uses)

• Signature, credentials, date: (the clinician who performed the service)

Two lines carry the level. "Problems addressed today" and "Risk of management selected" are what a reviewer reads to decide whether the code was right, and they are the two most often written as a single vague sentence.

Where Sully.ai Fits in Coding an Office Visit

The level is decided by what the note evidences. The note is usually written after the visit, from memory, between patients.

What gets lost in that gap is specific: the second problem you addressed briefly, the data you reviewed before walking in, the reasoning behind continuing a medication rather than changing it. Those are the three medical decision making elements, and all three were spoken aloud in the room.

Sully.ai's AI scribe drafts the note from the visit, so the problems addressed, the data reviewed and the risk are on the page rather than reconstructed later. It runs on a single integration across Epic, Cerner, Meditech and Athenahealth.

Two boundaries, and the first is a refusal.

Nothing should choose the code. Code selection is your attestation, it is what an auditor examines, and it carries liability that belongs to the person who saw the patient. A tool that picks the level and asks you to approve it has moved that decision without moving the responsibility.

A scribe cannot evidence what was never said. If you managed a second chronic problem silently, in your head, while examining something else, there is nothing to capture. The visit supported a higher level and the record will not show it.

Sully operates across 5,000+ providers, has delivered 50M+ hours of work, and prices each role 80 to 90 percent below the human equivalent [5].

Two Worked Examples

A Visit That Is Clearly 99213

Established patient, last seen 4 months ago. 12 minutes face to face, 19 minutes total.

Chief complaint: "I just need a refill on my blood pressure medication."

History relevant to today: Hypertension, diagnosed 2019, on lisinopril 20mg daily. No headaches, no dizziness, no chest pain. Taking the medication daily, no missed doses reported. Home readings averaging 128/78 over the past month.

Examination: Blood pressure 130/80, heart rate 72 regular. Chest clear. No peripheral edema.

Problems addressed today: Essential hypertension, stable.

Data reviewed: Home blood pressure log brought by patient. No new labs this visit.

Risk of management selected: Continue current therapy unchanged. Low risk.

Route used: Medical decision making.

Assessment and plan: Hypertension well controlled on current dose. Continue lisinopril 20mg daily. Repeat renal function and electrolytes in 6 months. Review in 6 months, sooner if home readings exceed 140/90 consistently.

One stable chronic illness, minimal data, low risk management. Two of three elements at low. This is a 99213 on the decision making route, and it would not reach the time threshold either.

A Visit That Looks Like 99213 and Is Actually 99214

Same patient, same presenting complaint, four months later. Watch what changes.

Chief complaint: "Blood pressure refill again, and my sugars have been running high."

History relevant to today: Hypertension, stable on lisinopril 20mg. Also type 2 diabetes, diagnosed 2021, on metformin 1g twice daily. Home glucose readings running 160 to 215 mg/dL over the past six weeks, higher than her usual 110 to 145. No polyuria, no weight loss, no infections.

Examination: Blood pressure 132/82. Feet examined, sensation intact, no ulceration.

Problems addressed today: Essential hypertension, stable. Type 2 diabetes, worsening glycemic control.

Data reviewed: HbA1c from 3 days ago, 8.4 percent, up from 7.1 percent six months ago. Home glucose log.

Risk of management selected: Adding a second oral agent. Prescription drug management.

Route used: Medical decision making.

Assessment and plan: Hypertension controlled, continue lisinopril unchanged. Diabetes with deteriorating control confirmed on HbA1c. Starting empagliflozin 10mg daily, counseled on genitourinary infection risk and sick day rules. Repeat HbA1c in 3 months. Review in 6 weeks.

What moved it. Two problems addressed rather than one, and one of them is worsening rather than stable. An external test result reviewed. A new prescription started, which is prescription drug management and moderate risk on its own.

The visit took a few minutes longer than the first. The documentation took the same time to write. The difference between the two codes was already true of the patient, and the second note simply records it.

FAQ

What is CPT code 99213?

The office or other outpatient visit for an established patient at a low level of medical decision making, or 20 to 29 minutes of total time on the date of the encounter [4]. It is one of the most frequently reported codes in outpatient medicine.

How much does CPT code 99213 pay?

There is no single figure. Medicare computes the fee schedule amount as the RVUs for the service multiplied by the geographic adjustment factor for your area and the conversion factor [1], so it varies by locality and by year. Get the current number for your locality from the CMS Physician Fee Schedule Look-Up Tool [3]. A non-participating supplier is paid 95 percent of the participating amount [1].

What is the difference between 99213 and 99214?

The level of medical decision making, or the total time. 99213 is low decision making, or 20 to 29 minutes. 99214 is moderate, or 30 to 39 minutes. In practice the two things that most often move a visit up are a second stable chronic illness and prescription drug management [6].

Why would CPT code 99213 be denied?

Most commonly because the patient was not established, because the note evidences neither the time route nor the decision making route, because the visit was bundled into a same-day procedure without the appropriate modifier, or because the diagnosis submitted does not support medical necessity.

Can an AI scribe pick the right code?

It should not, and Sully.ai does not. Code selection is your attestation and it is what an auditor examines. What a scribe does is make sure the note carries the problems addressed, the data reviewed and the risk, so whichever level you select is supported by what is written.

Sources

[1] U.S. Government Publishing Office — 42 CFR 414.20, Formula for computing fee schedule amounts. https://www.govinfo.gov/content/pkg/CFR-2023-title42-vol3/xml/CFR-2023-title42-vol3-sec414-20.xml

[2] U.S. Government Publishing Office — 42 CFR 414.22, Relative value units (RVUs). https://www.govinfo.gov/content/pkg/CFR-2023-title42-vol3/xml/CFR-2023-title42-vol3-sec414-22.xml

[3] Centers for Medicare & Medicaid Services — Physician Fee Schedule Look-Up Tool. https://www.cms.gov/medicare/physician-fee-schedule/search

[4] American Medical Association — CPT code 99213, established patient office visit, 20-29 minutes. https://www.ama-assn.org/practice-management/cpt/cpt-code-99213-established-patient-office-visit-20-29-minutes

[5] Sully.ai — AI Medical Scribe. https://www.sully.ai/medical-scribe

[6] American Academy of Family Physicians — Evaluation and Management Coding. https://www.aafp.org/family-physician/practice-and-career/getting-paid/coding/evaluation-management.html