99213 CPT Code Explained – Complete Billing Guide
If you’re a healthcare provider or office manager dealing with outpatient visits, you’ve likely encountered the 99213 CPT code. But what does it really mean, how is it billed, and why does it matter so much to your revenue cycle?
At Express Medical Billing, we’ve worked with countless providers navigating the nuances of CPT 99213. This guide breaks it all down for you from real-world experience to Medicare reimbursement rates and billing tips that reduce denials.
What Is the 99213 CPT Code?
CPT code 99213 is used for office or outpatient visits with established patients that involve a moderate level of evaluation and management complexity. It falls under the family of codes ranging from 99212 to 99215, with 99213 being the most commonly billed E/M code in primary care.
99213 CPT Code Description
According to the CPT manual, the official 99213 CPT code description includes:
This code is used for outpatient or office visits involving established patients where a low level of medical decision-making is needed and a relevant history and/or exam is performed. If billing based on time, the visit must last between 20 to 29 minutes on the same day.
This means you’re typically seeing a patient for routine follow-up, chronic illness management, or mild acute symptoms.
99213 CPT Code Time Range
Time-based billing has gained importance, especially with recent E/M guideline changes. The 99213 CPT code time range is 20 to 29 minutes. This includes:
- Face-to-face time
- Time reviewing patient records
- Ordering tests
- Documenting care
- Counseling the patient
99213 CPT Code Reimbursement Rates
Reimbursement varies depending on your payer private insurance, Medicaid, or Medicare.
99213 Reimbursement Medicare:
As of 2025, Medicare reimburses approximately $96–$101 for CPT 99213, depending on geographic adjustments.
Private Payers:
Commercial plans normally reimburse b/w $110–$135 for this code.
Express Medical Billing always encourages verifying payer contracts and local fee schedules to get accurate rates.
99213 CPT Code RVU Value
In 2025, the Relative Value Unit (RVU) for 99213 is approximately 1.30. RVUs are critical in calculating reimbursement using the formula:
Payment = RVU Ă— Conversion Factor
This metric helps providers assess productivity and compensation in RVU-based systems.
99213 CPT Code Cost to Patients
For insured patients, co-payments range from $10 to $50, depending on the plan. For uninsured patients, the 99213 CPT code costs can range from $90 to $160 per visit. Transparency is key considers clearly displaying pricing if you serve self-pay patients.
Modifiers for 99213 CPT Code
Modifiers add detail about how or why a service was provided, especially when bundling services. Here are key ones:
Modifier 25:
Applied when a distinct and medically necessary evaluation and management (E/M) service is provided on the same day as another procedure.
Example: You treat a rash (E/M) and perform a minor skin biopsy (procedure) — you’d bill 99213-25.
Other Common Modifiers:
- Modifier 95: Used for telehealth services
- Modifier 24: Used for unrelated E/M during post-op periods
Correct modifier use prevents rejections and improves claim approval—something our team at Express Medical Billing helps clients with daily.
99214 vs 99213 CPT Code - Know the Variance
CPT code 99214 is used for office visits that involve moderate medical decision-making or when the total time spent with the patient ranges from 30 to 39 minutes. Here’s a quick comparison:
Feature | 99213 | 99214 |
Complexity                     | Low | Moderate |
Time Range | 20–29 minutes                | 30–39 minutes |
Documentation Needed | Less extensive | More detailed |
Reimbursement | ~$101 (Medicare) | ~$144 (Medicare) |
Choosing the right code matters not just for compliance, but for accurate payment.
Real Insight from Billing Experts
At Express Medical Billing, we’ve seen firsthand how incorrectly billed 99213 codes lead to denials, underpayments, or audits. One clinic we helped was unknowingly billing 99214 for all follow-ups even quick medication refills.
This triggered a payer audit. By reassessing their visit lengths and documentation, we helped them correctly transition to 99213 and 99212 where appropriate avoiding over coding risk and stabilizing their cash flow.
Final Thoughts
Mastering the 99213 CPT codes doesn’t just ensure clean claims—it protects your practice’s reputation and revenue. Whether you’re a solo provider or a large multispecialty group, correct coding is important.
Need help with accurate CPT coding, claim submission, and denial management?
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Frequently Asked Questions (FAQs)
A visit qualifies for CPT 99213 when a provider sees an established patient for a moderately complex evaluation like managing chronic conditions, adjusting medications, or addressing new but non-urgent symptoms. It’s ideal for visits that require some decision-making but not extensive problem-solving.
Yes, you can bill 99213 for telehealth visits as long as the service meets the same documentation standards as an in-person visit. Just be sure to append Modifier 95 to indicate the appointment occurred via an approved telehealth platform.
The difference lies in time and complexity. Usage 99213 for visits long-term 20–29 minutes with low complexity choice-building. Choose 99214 when managing multiple or unstable conditions, or if the visit extends 30–39 minutes.
Absolutely. Your documentation should clearly reflect the medical necessity, history, exam findings, and decision-making level. If you're billing based on time, ensure the total time spent on the date of service is accurately recorded.
Yes. Modifier 25 allows you to bill 99213 with a procedure performed during the same visit as long as the E/M service is separately identifiable. This is common when treating a condition and performing a minor in-office procedure on the same day.
For 2025, Medicare reimbursement for CPT 99213 averages around $96–$101, but this can vary based on location. Private payers often reimburse $110–$135. Make sure your practice checks payer-specific fee schedules to confirm exact amounts.
