CPT Code 99213: Established Patient Office Visit, Requirements and Reimbursement

A blood pressure follow-up, twenty minutes with the clinician, one prescription renewed. Most practices bill that visit as 99213 without a second thought, and most of the time they are right. The money is lost at the edges: the 15-minute visit that actually supports 99214, the 25-minute visit padded with a medical assistant’s minutes, the note that never says which rule set the level.

CPT code 99213 is the established-patient office visit that billers and coders handle most days. This guide shows what medical code 99213 requires, where it starts and stops by time and by medical decision making (MDM), what Medicare pays for it in 2026, and the documentation that keeps it paid.

Quick answer: CPT code 99213 is the level 3 office or outpatient visit for an established patient. It is supported by low medical decision making (two of the three MDM elements at the low level) or by at least 20 minutes of the billing practitioner’s own time on the date of the visit. Medicare’s 2026 national rate is $95.19 in the office, before locality adjustment.

What Is CPT Code 99213?

CPT 99213 reports an office or other outpatient evaluation and management (E/M) visit for an established patient. The visit needs a medically appropriate history and/or examination, and the level is set either by low-level medical decision making or by total time on the date of the encounter (AMA). It is the third of the five established-patient levels, 99211 through 99215. The AMA’s typical patient for the code has a stable chronic illness or an acute uncomplicated injury.

The history and exam no longer set the level. Since 2021 they only need to be medically appropriate for the problem; counting history and exam elements, the pre-2021 method, does not decide anything for office visits.

Established, not new: A patient is established when they received professional services from the same physician or other qualified health care professional, or from another one of the same specialty in the same group, within the previous three years. CPT also requires the same subspecialty, so a colleague in a different subspecialty can see the patient as new.

Medicare’s version of the rule is in the CMS E/M services booklet (MLN006764). A patient who changes doctors inside the same group, specialty and subspecialty stays established. Anyone outside the three-year window bills from the new-patient range, where CPT 99203 is the low-MDM equivalent. The new-patient code pays more, not less: $117.57 nationally in the office in 2026 against $95.19 for 99213, which is why payers watch for established patients billed as new. Our new patient code range guide walks through the three-year rule with examples.

Time and Medical Decision Making Rules for 99213

There are two ways to support 99213, and they are alternatives. The level can be selected by MDM or by total time, and the record has to support whichever one the practice uses.

Selecting 99213 by Total Time

Office visit codes now list a single time that must be met or exceeded. For 99213 that is 20 minutes of total time on the date of the encounter, as Noridian’s 99212 to 99215 review results state it. The AMA’s own 99213 page and the CGS Medicare fact sheet still print “20 to 29 minutes”. The practical effect is the same, because 30 minutes meets the 99214 threshold. What matters is that there is no rounding up: CMS tells practitioners selecting by time that they must provide the full time, so 19 minutes is a 99212 by time.

Total time is the physician’s or other qualified health care professional’s own time that day, face to face and not. According to CGS Medicare’s E/M fact sheet, it can include:

• Preparing for the visit, such as reviewing test results.
• Obtaining or reviewing a separately obtained history.
• Performing a medically appropriate examination or evaluation.
• Counseling and educating the patient, family or caregiver.
• Ordering medications, tests or procedures.
• Referring to and communicating with other health care professionals, when not reported separately.
• Documenting in the health record.
• Interpreting and communicating results, and coordinating care, when not reported separately.

What does not count: time spent separately by clinical staff, such as a medical assistant rooming the patient; time spent on services reported separately, such as a procedure or a test interpretation billed on its own; and any work done on a different date.

Two more rules apply when more than one practitioner is involved. CPT counts only distinct time: when two professionals meet about the patient, only one of them can count those minutes. And Medicare does not allow office visits to be billed as split or shared visits, so one practitioner bills the 99213, either under their own NPI or incident to a physician when the incident-to rules are met (CMS MLN006764).

Selecting 99213 by Medical Decision Making

MDM has three elements: the problems addressed, the data reviewed and analyzed, and the risk of patient management. A visit reaches a level when at least two of the three elements reach it (AMA MDM table). A problem counts only if it is addressed at the visit, meaning evaluated or treated; a condition that is merely listed, or noted as managed by someone else, does not count.

MDM Element	Straightforward (99212)	Low (99213)	Moderate (99214)
Problems addressed	1 self-limited or minor problem	2 or more self-limited or minor problems; or 1 stable chronic illness; or 1 acute uncomplicated illness or injury; or 1 stable acute illness	1 or more chronic illnesses with exacerbation, progression or treatment side effects; or 2 or more stable chronic illnesses; or 1 undiagnosed new problem with uncertain prognosis; or 1 acute illness with systemic symptoms; or 1 acute complicated injury
Data reviewed and analyzed	Minimal or none	Limited: any 2 of external notes reviewed (each unique source), unique test results reviewed, unique tests ordered; or an assessment needing an independent historian	Moderate: any 3 of those items (historian included); or independent interpretation of a test performed by another physician; or discussion of management with an external physician or other appropriate source
Risk of patient management	Minimal risk of morbidity from testing or treatment	Low risk of morbidity from testing or treatment	Moderate risk, for example prescription drug management

Two definitions decide most borderline charts. A chronic illness is stable when the patient is at their treatment goal; one that is not at goal is not stable, even if nothing has changed, and counts as a chronic illness with progression. And a test you order counts once: reviewing its result at a later visit is part of having ordered it, not a second data point.

Where Prescription Drug Management Fits

Prescription drug management is listed as an example of moderate risk. On its own it sets one element, not the visit. Two common misreadings follow from that.

• It does not guarantee 99213. A minor, self-limited problem treated with a prescription, with no data reviewed, has one element at moderate and two at minimal. Only one element reaches the low level, so MDM is straightforward and the visit supports 99212 by MDM.
• It can push a visit past 99213. Two or more stable chronic illnesses, each addressed at the visit, are a moderate-level problem. Add prescription drug management and two elements sit at moderate, so the visit supports 99214, however short it was.

Billing that second visit as 99213 leaves $40.42 per visit at the 2026 Medicare national office rate.

99212 vs 99213: The Difference Between the Two Codes

The difference between CPT code 99212 and 99213 is one level of MDM or ten minutes of practitioner time. Straightforward MDM or at least 10 minutes supports 99212. Low MDM or at least 20 minutes supports 99213. Nothing else separates them: not the diagnosis, not the appointment type, not how long the patient sat in the waiting room. For more on the lower code, see our CPT code 99212 guide.

99212 vs 99213 at a Glance

Code	Time on the Visit Date (Met or Exceeded)	MDM Level	Typical Visit	2026 Medicare National, Office
99212	10 minutes	Straightforward	One minor, self-limited problem	$59.45
99213	20 minutes	Low	One stable chronic illness or one acute uncomplicated illness or injury	$95.19
99214	30 minutes	Moderate	Two or more stable chronic illnesses addressed, or one chronic illness not at goal or worsening	$135.61

The 2026 office gap between 99212 and 99213 is $35.74 a visit at the national rate, and on the 99213 vs 99214 line it is $40.42. Habitual downcoding hands that money back on every visit. Habitual upcoding builds an overpayment that a payer can later recoup, as our guide to payer audit recoupments explains.

Boundary Examples

These are hypothetical visits, simplified to show the rule.

• 99212. An established patient with an insect bite. The clinician examines it and recommends an over-the-counter cream. One minor problem, no data, minimal risk; 12 minutes of total time.
• 99213. A follow-up for hypertension, with the patient at their blood pressure goal. The clinician reviews a metabolic panel ordered by another practice, orders a lipid panel, and recommends diet changes with a recheck in three months. One stable chronic illness (low), two data items (limited, so low), low-risk management: MDM is low. The outside panel counts as a reviewed result because this practice did not order it; the lipid panel counts once, as an order.
• Still 99213 with a prescription. The same visit with a prescription renewed adds prescription drug management (moderate risk), but only one element reaches moderate. MDM stays low.
• 99214. A patient whose hypertension and type 2 diabetes are both at goal. The clinician evaluates both and renews both prescriptions. Two stable chronic illnesses addressed (moderate) plus prescription drug management (moderate): moderate MDM, even in a 15-minute visit. If the clinician instead raises the metformin dose because the A1c is above goal, the diabetes is not stable; it becomes a chronic illness with progression, which is still a moderate-level problem.

CPT Code 99213 Reimbursement Rates

Medicare’s 99213 CPT code reimbursement is built from relative value units (RVUs) for physician work, practice expense and malpractice, multiplied by the annual conversion factor and adjusted for the practice’s locality. For 2026, CMS finalized two conversion factors: $33.40 for most practitioners and $33.57 for qualifying APM participants (CMS fact sheet, CY 2026 PFS final rule). The amounts below use the first, which is $33.4009 unrounded.

2026 Payment Rates for CPT Code 99213

Setting	2026 Total RVUs	2026 National Amount	2025 National Amount	Change
Non-facility (office)	2.85	$95.19	$88.95	+7.01%
Facility (for example, hospital outpatient department)	1.72	$57.45	$63.72	-9.84%

Two 2026 changes explain the split. E/M visits are time-based services, so they were exempt from the 2.5% efficiency cut CMS applied to the work values of most other services. And CMS changed how indirect practice expense is spread, recognizing more indirect cost for office-based care than for facility settings (CMS). Office payment rose; the facility rate, paid to the practitioner when the visit happens in a hospital setting, fell.

What Changes the Amount You Are Paid

• Locality. CMS adjusts every amount by geographic practice cost indices. The CMS Physician Fee Schedule Look-up Tool shows the figure for your Medicare locality.
• Who bills. Medicare pays nurse practitioners and physician assistants billing under their own NPI 85% of the fee schedule amount; services billed incident to a physician are paid at 100% when incident-to rules are met (MedPAC). At the national office rate, 85% of $95.19 is $80.91. Incident-to billing requires that the physician personally initiated the course of treatment and stays actively involved (Medicare Benefit Policy Manual, ch. 15, §60.2), so a visit where an NP or PA works up a new problem generally belongs under the NP’s or PA’s own NPI.
• Cost sharing and sequestration. The fee schedule amount is the allowed amount. The patient’s Part B deductible and coinsurance come out of it, and Medicare’s share is further reduced by sequestration.
• Payer. Commercial plans pay the rate in their contract, and state Medicaid programs publish their own fee schedules. The Medicare figure is a benchmark, not a promise.

Pro tip: Pull the locality-adjusted rate for 99212 through 99215 every January. Part of the 2026 increase was a one-year 2.5% statutory update, and CMS’s CY 2027 proposed rule projects a lower conversion factor for 2027 ($32.84 for most practitioners).

Adding G2211 to a 99213

Medicare’s G2211 add-on recognizes the longitudinal work of being the continuing focal point for a patient’s care, or of ongoing care for a single serious or complex condition. It can be reported with 99213 when that relationship exists and the record shows it (CMS MLN006764). The 2026 national office amount is $17.37.

The modifier 25 rule trips practices up. Medicare generally does not pay G2211 when the 99213 carries modifier 25. Since January 1, 2025, the exception is a 99213 with modifier 25 billed by the same practitioner on the same day as an annual wellness visit, a vaccine administration or another Medicare Part B preventive service; then G2211 can be paid. Commercial payers set their own G2211 rules.

Proposed for 2027: CMS’s CY 2027 proposed rule (July 14, 2026) would replace G2211 with a payment modifier on the E/M code that raises its payment by 16%, or 32% for practitioners in the Shared Savings Program or the LEAD model (CMS fact sheet). As of October 28, 2026 the final rule had not been released, so the 2026 G2211 rules above still apply.

Documentation and Billing Rules That Protect 99213 Claims

A 99213 note should let a reviewer see the visit without asking anyone. The CGS Medicare fact sheet lists what reviewers look for: the reason for the encounter, relevant history and exam findings, prior results, the assessment and plan, the patient’s progress and response to treatment, diagnosis codes that match the claim, and a legible signature with credentials. Late entries and amendments must be identified as such.

Then the note has to show the basis for the level:

• When time sets the level, state the practitioner’s total time on the date of the visit and what it was spent on. “Total time today 24 minutes, including review of outside labs and documentation” holds up; “25-minute visit” does not.
• When MDM sets the level, name the problems addressed and their status against goal, the data reviewed or ordered, and the management decision. A reviewer reads for those three things.

Modifier 25 with 99213

Modifier 25 tells the payer that a significant, separately identifiable E/M service happened on the same day as another service or procedure. With a preventive medicine visit or a Medicare annual wellness visit, a problem-oriented 99213 can be billed alongside it when the problem needs work beyond the preventive service. A trivial or insignificant problem handled in passing does not justify the extra code (AMA). The work counted toward the 99213 should be the problem-oriented work, documented so it can be told apart from the preventive service.

With a minor procedure, the decision to perform the procedure is already included in the procedure’s payment, so it cannot be the reason for a separate 99213. A separate E/M is reportable when the clinician does significant work beyond that, and the two services may share the same diagnosis (AAFP). Leaving modifier 25 off a separately identifiable visit can trigger a modifier-related denial such as CO-4; adding it automatically is the opposite risk.

Proposed for 2027: CMS’s CY 2027 proposed rule (July 14, 2026) would pay the higher-valued service in full and the other at 50% when an office E/M visit and a procedure with a 0-, 10- or 90-day global period are furnished on the same day by the same physician or practice (CMS fact sheet). The final rule had not been released as of October 28, 2026.

Billing 99213 for Telehealth

Office visit codes, including 99213, can be furnished by telehealth when the payer covers it. For Medicare, the Consolidated Appropriations Act, 2026, signed February 3, 2026, extended the Medicare telehealth flexibilities, including visits with patients at home, through December 31, 2027 (HHS telehealth policy updates). Place-of-service and modifier instructions differ by payer and have changed several times since 2020, so take them from CMS’s current telehealth guidance and from each commercial payer’s policy rather than from an old template.

Where 99213 Claims Usually Fail

• Cloned notes. A template that reads the same at every visit gives a reviewer nothing to tell the encounters apart.
• Time that does not qualify. Minutes that are not the practitioner’s own, or that come from another day, inflate the total.
• Patient status. A patient seen in the group within three years billed as new, or the reverse.
• Element counting. Notes built to satisfy pre-2021 history and exam rules, with the MDM left implicit.
• Problems listed, not addressed. A problem list copied forward does not add problems to the MDM.
• Modifier 25 errors. Missing when the visit was separate; present when it was not.
• G2211 on a modifier 25 claim when the other same-day service was not a Medicare preventive service, vaccine administration or wellness visit.

Before You Bill 99213: A Pre-Claim Check

Run each 99213 claim through these checks before it goes out. Tick only what the chart in front of you actually shows; anything left unticked is the fix before the claim leaves.

1. Patient status confirmed. The patient received professional services from this practitioner, or a colleague of the same specialty and subspecialty in the group, within the last three years.
2. Basis named. The note states whether time or MDM set the level.
3. Time, if used, is the practitioner’s own and from the visit date, with at least 20 minutes documented, and no clinical staff minutes or time on separately reported services included.
4. MDM, if used, shows two of three elements at low or higher: the problems addressed and their status, the data, and the management decision.
5. Level checked against 99214. Two or more stable chronic illnesses addressed with prescription drug management, or 30 or more minutes, support 99214 instead.
6. Modifier 25 matches the day. Present when a separate problem-oriented visit happened alongside a preventive service or procedure, absent when it did not.
7. G2211 rules met if it is added, including the modifier 25 exception for preventive services.
8. Place of service and diagnosis codes match the visit, including telehealth settings and the problems actually addressed.

The Bottom Line

CPT code 99213 has simple rules and unforgiving documentation. Low MDM or 20 minutes of the practitioner’s own time supports it, and the note has to say which. Practices that check billed levels against charts on a schedule, rather than after a denial, keep the payment they earned. For support across the revenue cycle, see our medical billing and RCM services.

Frequently Asked Questions

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Sources: CMS, Evaluation and Management Services (MLN006764, September 2025); CMS, CY 2026 Physician Fee Schedule final rule fact sheet (October 31, 2025); CMS, CY 2027 Physician Fee Schedule proposed rule fact sheet (July 14, 2026); CGS Medicare, E/M office and outpatient fact sheet; Noridian, 99212 to 99215 review results; AAFP, How to use modifier 25.

Published by the Health Med Affairs editorial team. Health Med Affairs provides medical billing, coding, credentialing, and clinical documentation support to U.S. physician practices. This article is educational information, not legal advice and not coding advice for a specific claim; payer contracts and state laws vary.