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.
Billing guidance for 99213 is locked
- When to use it: the exact clinical situations that support billing 99213
- Documentation checklist: the 5 elements your note needs before submitting
- Common pitfalls: the 5 mistakes that get 99213 downcoded or denied
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.