Intro
Are you confused about when to use code 99213? It’s designed for established patient office visits and is commonly used by providers.
However, don’t use it out of habit, as misuse can lead to problems. Code 99213 has clear rules, and insurers require evidence in your documentation to support its use for a specific level.
We’ll break down what code 99213 medical coding really means, when to use it, and what your documents should contain before you submit it on a claim. So, let’s begin!
What Does CPT Code 99213 Mean?
It’s a routine checkup code used in clinics. It is used for an established patient visit when:
- The doc does a checkup and a basic exam
- The visit includes a low-level Medical Decision-Making (MDM) checkup
- OR the patient spends only 20-29 minutes with the doctor during that visit.
Moreover, when a patient feels they must have an “everyday doctor visit” to get a routine checkup, then go for it. This routine checkup may include the following:
- Adjusting medications
- Managing ongoing conditions
- Checking lab results
- Discussing your treatment plans
For example, a patient, Mario, has a problem of fluctuating BP, and now he has come in for medicines that need to be changed, take BP readings, or have some other discussions. For that visit, code 99213 will be used.
Code 99213 medical coding doesn’t include the visit in which the complex medical condition is discussed. It’s the kind of visit in which regular things are discussed, which are practical, important, and necessary, without being high-risk or complicated.
In addition, the patient’s symptoms, medical history, examination, and the provider’s work must match the requirements for 99213.
Established Patient Visit 99213
Why is it used for established patients? Before giving any service, doctors only confirm whether the patient is new or established (old/previous). In E/M coding, a patient is considered established if:
- They have visited the same doctor before
- They have seen another doctor in the same group and specialty (cardiologist, radiologist, orthopedic, physiotherapist, etc) within the last 3 years
If the patient is new and doesn’t have any recorded data for the past three years, the doctors use codes between 99202-99205 for him.
Documentations Required
To use the 99213 code, providers have to decide on two factors:
- Time spent
- Decision-making complexity
If you use time-based 99213 billing, keep in mind that:
- The total time for that particular visit is 20-29 minutes
- It is an in-person visit
- Or it includes the same-day reviewing test reports, or after reports, the discussion includes what the treatment plan should be
If you use the MDM complexity factor, it must include:
- You have treated two minor problems in that visit
- You have managed one stable chronic condition during that visit
In other words, to use 99213 billing, your notes must have the following:
- What actually happened during that visit
- Why was the service given
Your documents should be clean, it can lead to:
- Claim denials
- Downcoding
How to Choose 99213 Based on MDM
If you want to use 99213 coding, make sure the level of Medical Decision Making (MDM) is low. It depends on the following three elements:
- The data of a patient you reviewed
- The problems you handled
- The chances of risk in your treatment plan
Let’s have a deep look:
- Problems Handled
You manage and handle problems under code 99213 medical coding that are usually simple and easy to tackle. For example:
- A stable chronic condition: controlled BP, diabetes, or depression that can be treated with medicines
- Two small and short-term ailments
- One minor acute issue: sinus infection, mild skin rash, simple UTI, or red/pink eye
As you can see, MDM involves handling only minor cases, routine checkups, or low-risk ailments. 99213 billing codes cannot cover multiple serious diseases or complex medical situations.
- Data Ordered
For a routine visit, you have to review a small amount of data, such as:
- Looking at your previous prescriptions and vital signs
- Checking 1-2 lab reports
- Quickly examining a recent imaging report
- Ordering a simple or routine blood test
But if you think the data review is going beyond the above consultations, the billing will be covered under a high-level code like 99214. Check the difference in the next section!
- Morbidity or Complications
Your treatment plan should involve the following low-risk tasks:
- Scheduling a routine follow-up
- A slight change in medicines
- Giving basic advices
- Prescribing short-term medicines
Again, you can’t make any major surgery decisions or prescribe high-risk medications under code 99213 medical coding.
Interestingly, at least two out of three areas, such as data, problems, and risk, must fall under the criteria of MDM to use 99213.
How to Use Code 99213 Medical Coding Based on Time
In addition to MDM, time spent also plays an important role in choosing 99213 coding. In simple words, the time a doctor spends with a patient on the same day is actually the time spent, which is accurately 20-29 minutes only.
This is what you can do in 20-29 minutes patient’s visit:
- Order imaging and labs test
- Discuss with the patient’s family about the history or doing any medical exam
- Review any previous current charts and test reports before the visits
- Explain what you diagnose, and explain what treatment options are available
- Coordinate care
Time is so important to specify a medical code. One minute less or more can totally change the code you have to mention on the documents, such as:
- 20-29 minutes: 99213
- Less than 20 minutes: 99212
- 30 minutes or more: 99214
If you want to avoid claim denials, it’s a good idea to mention:
“Total provider time today: 25 minutes spent reviewing records, taking medical history, performing exam, counselling the patient, and documenting the visit.”
When NOT to Use 99213?
The code 99213 medical coding should be used correctly; you can face claim denials or lost revenue. Here’s where you can’t use 99213:
- A very simple visit
If the patient takes only 5-10 minutes, it will be referred to as a quick checkup, and 99213 will be so high coding for this quick checkup. So, you have to use 99212 coding under this visit that may include the following:
- You didn’t review the data in detail
- The visit was quite short
- You didn’t make any major changes to the treatment plan
- A patient asked a few questions and went away
Two to three talks can bring 99212 to the documents.
- More Complex Case
If the patient takes more than 30 minutes and a little extra detailing is required to satisfy your patient, 99214 coding will be used. Here’s what 99214 covers:
- If the patient’s disease gets more serious or unstable
- You change the treatment plan that may have a risk
- You prescribed more tests or reviewed complex data
- You handle more than one problem in a single visit
If you have to do a deep analysis, deep thinking, or need more time to make a decision, use 99214 instead of 99213.
- New patient
Keep in mind that 99213 is only used for established patients. If the visit looks like 99213, you can’t use it for new patients. They need 99292 to 99205 coding.
The Key Differences Between 99213 and 99214
CPT 99213 and 99214 codes are E/M or Evaluation and Management codes used for established outpatient visits. The difference relies on the time spent, level of complexity, and documentation required.
CPT 99213 requires a problem-focused history. It means you have to document the patient’s main problem along with a brief history of the present illness (HPI). This includes a few basic details such as where the problem is, how severe it is, and how long it has been present. This straightforward documentation is ideal for routine or less complicated cases.
CPT 22914, on the other hand, is used for more complex visits and requires much more detailed documentation. In 99214 documentation, you have to add four elements of HPI and a Review Of two to Nine Body Systems (ROS). also add one part of the patient’s Past, Family, or Social History (PFSH).
Code 99213 medical coding is also known as a level 3 visit. On the flip side, 99214 is referred to as a level 4 visit. Here’s the key difference below:
| Features | 99213 | 99214 |
| Level | 3 | 4 |
| Time Spent | 20-29 minutes | 30-39 minutes |
| MDM | Low complexity | Moderate complexity |
| Risk of Complications | Low | Moderate |
| Data Review | Small or none in some cases | Labs, images, or previous doctor’s records |
| Number of Diagnoses | 1-2 stable conditions | Multiple conditions or new problems |
In simple terms, 99213 is for basic and short visits with short details, while 99214 is for more involved cases that need a deeper and more complete evaluation. Hence, a small change can shift medical coding. So, it’s crucial to be careful while using medical coding.
What’s the Impact of Code 99213 Medical Coding on Reimbursement?
You can get $75 to $95 under code 99213, depending on the insurance company and location. Furthermore, not all insurance companies accept this code. For instance, only Medicare and private insurers accept it, and the exact payment may vary based on contracts and policies.
This is the payment criteria under code 99213 medical coding:
- Medicare pays about $80 to $90
- Commercial or private insurance may pay a little extra, such as $100 or slightly higher
If you want to make your payment system hassle-free, use these codes carefully. If you use higher coding, your documents may be called for audits and reviews. This may consume your time and disturb your schedule.
On the flip side, if you use lower coding instead of using 99213, you can lose revenue you actually deserve.
Modifiers Used With 99213 CPT Code
In some cases, providers have to use some modifiers to explain some special situations during a routine checkup of a patient. These modifiers help to show why the visit is more complex than a routine checkup.
These modifiers are as follows:
Modifier 25
This modifier (-25) is used when a doctor does a procedure in addition to another evaluation. For example, a patient comes in for sinus infection treatment, and after getting the treatment, he also complains about skin lesions. Hence, in the same visit, he gets skin lesion removal and sinus treatment.
For the separate service, use 99213-25 as medical coding.
Modifier 24
This modifier is used when a patient is undergoing recovery from a surgery and gets treatment for another ailment during the same visit. For instance, a patient recovering from leg surgery visits the doctor for diabetes. If the code 99213 medical coding is to be used, use it as 99213-24.
Modifier 57
This modifier is used when a patient comes in with severe pain, and the doctor immediately decides to do surgery. This isn’t a routine follow-up, just a moment when a surgery is decided.
For example, a patient comes with severe pain in the lower right abdomen, and the doctor diagnoses it as appendix pain, which needs to be removed. This visit can be reported as 99213-57.
Modifiers are actually extra labels that explain to the insurance company what made the visit special or different.
Mistakes to Avoid While Using 99213 Billing Code
A small mistake can lead to a huge loss in reimbursement. Hence, there are some mistakes that you must avoid while using the 99213 code:
Do Not Use 99213 In Every Visit:
Take care of the patient’s visit duration and MDM. If the visit time exceeds 20-29 minutes and goes up to an hour or more, it can never be recorded as 99213. This mistake can happen only when your patient is established and visits you quite often. So, using 99213 shouldn’t be habitual and should be used while considering time.
Do Not Undercode:
Sometimes, the patient takes about 20-22 minutes, and the providers use 99212 instead of 99213 even when they:
- Adjust treatment
- Review lab results
- Discuss a little
This leads to lost revenue over time.
Documents Don’t Cover Enough Details:
Do not use short phrases to show what happened in the visit, such as “patient stable” or “labs reviewed”. Instead, add a little detail to make it clear for insurance companies, such as:
- What are the test reports?
- What action was taken to cure the disease
- Which lab report was reviewed
These details can only justify code 99213 medical coding.
Overcoding Short Visits:
You can’t use 99213 for a short visit like basic reassurance. It can cause claim denials and extra scrutiny from insurance companies. Hence, always use the code that actually matches your level of service.
Do Not Mix MDM With Time:
Do not mention both things in the notes improperly. Write either one and document it clearly and completely.
In short, always use codes based on real work, document clearly, and avoid using the 99213 code habitually. This accurately calculates your bill and protects your revenue.
FAQs
Can code 99213 medical coding be used for telehealth?
Yes, you can use the 99213 code for telehealth services and a visit. Many insurance providers, such as Medicare, accept 99213 coding for telehealth visits as long as the visit meets all the required guidelines and documentation standards.
Can only doctors use the 99213 code?
No, it’s not only for doctors. Physician assistants, nurse practitioners, and other qualified healthcare professionals can also use this code under CPT 99213 guidelines.
How can practices ensure accurate coding and avoid revenue loss?
Practices should use professional billing and coding services that help keep documentation clear and consistent with insurer requirements. It can improve coding accuracy. You must review coding patterns regularly to ensure compliance. It also helps identify if any revenue is being missed.
In simple terms, using accurate code 99213 medical coding helps you get paid correctly while reducing the risk of audits, errors, or penalties.
Is CPT 99213 limited to certain age groups?
No, 99213 isn’t specific to any age. This code is used for established patients of any age. The complexity of the visit, time, and MDM matters the most for 99213.
What are the physical exam requirements for CPT 99213?
For CPT 99213, the physical exam is detailed but still focused. The doc checks the main problem area along with any related or symptomatic areas. Usually, the physical exam includes 6 to 11 exam findings, which can be normal or abnormal.
Conclusion
Code 99213 medical coding can only be used for a specific type of visit. It is used for established patient visits that include low-level MDM and take 20-29 minutes of the provider’s time, with clear and focused documentation.
Moreover, do not use it as a “default option” and make sure whether 99213 should be used or not. It saves you from claim denials and shows a clearer picture of the care your practice provides every day.
