99213
Office o/p est low 20 min
Office or other outpatient visit, established patient, low-level medical decision making OR 20-29 minutes of total time on the date of the encounter. The CMS 2026 wRVU for 99213 is 0.97, and Medicare allowable is calculated using the national GPCI and the 2026 conversion factor of $33.4009.
Modifier 25 carves an E/M out of a same-day procedure or preventive service. Here is when to use it, when to skip it, and the documentation that survives audit.
When to use it
Use 99213 for a stable established outpatient with one or two minor or stable problems, simple data review, and low-risk management. Typical patterns: routine refill of a stable chronic medication, follow-up on a single well-controlled chronic disease, simple URI evaluation, or a stable hypertension recheck with no medication change.
Full guidance
The 2021 MDM rubric requires low complexity on two of three elements (Problems Addressed, Data Reviewed, Risk). Time-based alternative is 20 to 29 minutes of total physician or QHP time on the date of the encounter. Pick the method that supports the strongest note: if the encounter clearly reflects low-complexity MDM, code by MDM and skip a time statement. Avoid the temptation to inflate to 99214 without a moderate-complexity MDM element.
Documentation checklist
- ✓MDM track: meet low complexity on at least two of three elements. Problems Addressed: limited (one self-limited, OR one stable chronic). Data Reviewed: limited (review of test results, or external notes, or independent historian). Risk: low (over-the-counter management, minor surgery without identified risk).
- ✓Time track: document total physician or QHP time on the date of the encounter, between 20 and 29 minutes. Include qualifying activities (chart review, ordering, counseling, documentation, communicating results, care coordination).
- ✓Pick one method per encounter. Mixing time and MDM in the same note invites confusion and a denial during audit.
- ✓Medical necessity must support the level regardless of method. The note must answer why this patient needed an established outpatient visit at this complexity.
- ✓If you bill a same-day minor procedure or counseling code, attach modifier 25 to the 99213 and document separate elements for each service.
Common pitfalls
- !Up-coding to 99214 without a moderate-complexity MDM element. CMS Comparative Billing Reports flag clinicians who report 99214 at rates more than two standard deviations above peers. The 99213 to 99214 ratio is one of the most audited deltas in primary care.
- !Counting non-billable activities toward the time threshold. Clinical staff time, time spent on a different date, and time on tasks unrelated to this patient do not count.
- !Billing time and MDM simultaneously. The 2021 guidelines explicitly let you pick one method; if both are documented, payers default to the lower-supporting method.
- !Missing the G2211 add-on when you are the longitudinal continuity provider. 99213 is the most common eligible primary code for G2211, and the national capture rate sits below 5 percent against an estimated 38 percent eligibility.
- !Forgetting modifier 25 when a same-day minor procedure (such as destruction of a skin lesion) is also billed. Without the modifier, the procedure bundles into the 99213 and the visit work is uncompensated.
Payer notes
Medicare and most commercial payers cover 99213 without prior authorization. Some Medicare Advantage plans audit 99213 to 99214 ratios at the practice level; expect a request for chart documentation if your panel-level moderate-complexity rate is high. Commercial payers occasionally apply place-of-service adjustments. For telehealth, verify your contract before billing 99213 with modifier 95 (audio-video) or GT (audio-only) at POS 02 or POS 10.