What constitutes a 99213 office visit?

Asked by: Alycia Hickle  |  Last update: August 12, 2025
Score: 4.8/5 (7 votes)

The 99213 code is specifically used for office visits that involve moderate medical decision-making and complexity. It is suitable for patients with established conditions or those with new, uncomplicated symptoms. These services encompass a range of primary care services that address the immediate needs of patients.

What is an example of a 99213 visit?

An example of a 99203 or 99213 is a sinus infection treated with an antibiotic. Although the prescription makes the risk component moderate, the one acute uncomplicated illness is a low-complexity problem, and there are no data points.

How do you know if it's 99213 or 99214?

The American Medical Association (AMA) outlines time requirements for these codes, reflecting the complexity of services rendered. CPT Code 99213: Generally involves 20 minutes spent on patient care. CPT Code 99214: Typically requires approximately 30 minutes spent with the patient.

What is considered a new patient office visit?

Medicare has stated that a patient is a new patient if no face-to-face service was reported in the last three years. The group practice and specialty distinctions still apply, but “professional service” is limited to face-to-face encounters.

What are the three main components of billing for an office visit?

Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity.

What is a level 3 or 2 office / outpatient visit in medical coding? 99213 & 99203 explained

28 related questions found

What are the criteria for billing 99213?

The 99213 code is specifically used for office visits that involve moderate medical decision-making and complexity. It is suitable for patients with established conditions or those with new, uncomplicated symptoms. These services encompass a range of primary care services that address the immediate needs of patients.

What determines the level of an office visit?

Medical decision making drives the level of office visit

The medical decision-making portion of evaluation and management guidelines is what ultimately determines the level billed. Higher complexity in decision making justifies higher levels.

What is considered a medical office visit?

An office visit is any direct personal exchange between an ambulatory patient and a physician or members of their staff for the purpose of seeking care and rendering health services.

What is the difference between 99213 and 99203?

Did you know? CPT 99203 is one of the nation's top 10 leading codes used in error? Many times clinics will use 99203 in error when they should select 99213 for a follow up. If your clinic has seen the patient within the last three years, the patient is not a "new consult", but rather a follow-up.

What is the 3 year rule for new patients?

The rule states that a patient is considered established if they have received face-to-face services from that provider or any other provider of the same specialty and same practice within the last three years.

What are the criteria for a 99214 billing?

According to CPT, 99214 is indicated for an “office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a detailed history, a detailed examination and medical decision making of moderate complexity.” [For more detailed ...

How do you know if its 99213 or 99214?

The primary difference between CPT code 99213 and 99214 lies in the complexity and time involved. While 99213 is for a low level of medical decision-making, 99214 is used for moderate complexity, requiring a higher level of medical decision-making and more extensive history and examination.

What constitutes a level 3 office visit?

Level-III visits are considered to have a low level of risk. Patient encounters that involve two or more self-limited problems, one stable chronic illness or an acute uncomplicated illness would qualify.

What is a complex office visit?

Complex visits are defined as those with over two diagnoses (the mean of diagnoses made per visit) and/or those with over three prescription medications (the mean of medications prescribed per visit).

Can you bill 99213 for telehealth visit?

During the COVID-19 public health emergency, many physiatrists are performing standard office visits via telehealth. These services should be billed using standard E/M codes. For example, a level 3 office visit provided to an established patient via telehealth should be billed using code 99213.

Is 99213 preventive?

However, if you bill an additional office visit code (for example, 15 minute expanded problem visit code 99213 with modifier 25), this is NOT considered a preventive service, and may be subject to deductibles, copays or coinsurance.

What is the difference between an appointment and an office visit?

An appointment is something you do to make something in a certain timespan now or in the future to have a possible contact with the clinic or anyone in the Clinic. A Visit is a result of an appointment and can be anything that that client has to do in the clinic for any sort of car.

What is the definition of an office visit?

An office visit is designed to discuss new or existing health issues, concerns, worries or symptoms. Your provider may order tests, prescribe medication, refer you to a specialist or provide advice and education. Office visits are covered by a standard insurance co-pay or deductible.

What is considered a routine office visit?

Routine care means seeing your PCP on a regular basis. It includes physical exams and bloodwork. Preventive care means specific things your provider does to help prevent disease. It includes vaccines, screening tests, and healthy lifestyle counseling.

What are the two categories of office visits?

There are two main categories for doctor visits. The first is called E&M (evaluation and management) and is when you need treatment for an active disease such as the flu, ear ache, bladder infection, diabetes or high blood pressure. The second type is a preventive visit, also called a physical or checkup.

What does code 99213 mean?

CPT® code 99213: Established patient office or other outpatient visit, 20-29 minutes.

Why am I being charged for an office visit?

The purpose of an office visit is to discuss or get treated for a specific health concern or condition. You may have to pay for the visit as part of your deductible, copay and/or coinsurance.