What is the reimbursement rate for CPT code 99213 in 2026?
The national average Medicare reimbursement rate for CPT code 99213 in 2026 is approximately $90 to $92 in a non-facility (office) setting, though exact payouts vary based on geographic location, local fee schedules, and commercial insurance contracts.
📊 2026 Reimbursement Breakdown
- ✅ Medicare National Average (Office): ~$90.00 – $92.00
- 📉 Medicare National Average (Facility): Lower, roughly $55.00
- 📈 Commercial Insurance Average: Higher, typically ranging from $82.00 to $160.00+ depending on the specific payer (e.g., Aetna, BCBS, UHC)
- 🛡️ Medicaid Average: Varies significantly by state, often averaging around $70.00
💡 Billing and Code Criteria for 99213
- Patient Status: Established patient (not a new patient).
- Time Threshold: 20 to 29 total minutes spent on the date of the encounter.
- Medical Decision-Making (MDM): Low complexity.
- Total RVUs: Approximately 2.75 total Relative Value Units for non-facility settings.
What is the average reimbursement for CPT code 99213?
The average national Medicare reimbursement for CPT code 99213 is approximately $90 to $95, while private commercial insurance typically pays between $80 and $130+ per visit.
Breakdown by Payer
- Medicare: Around $90–$95 for non-facility (office) settings, varying by geographic location and local wage index adjustments.
- Blue Cross Blue Shield (BCBS): Typically averages $91 to $105+ per visit, often higher than baseline Medicare rates.
- UnitedHealthcare (UHC): Generally reimburses around $86 to $93.
- Aetna & Cigna: Commercial averages range from $82 (Aetna) up to $101–$114+ (Cigna) depending on your region and specific network contract.
Opinions on billing and charges vary widely; as discussed on Reddit's Coding andBilling community, initial provider charges on an Explanation of Benefits (EOB) can be vastly higher (sometimes over $300–$500), but the actual allowed amount and contracted reimbursement received from the insurer is much lower.
What are the CMS reimbursement rates for 2026?
The CMS Medicare Physician Fee Schedule (MPFS) conversion factors for 2026 are $33.57 for qualifying alternative payment model (APM) participants and $33.40 for non-qualifying practitioners.
2026 Conversion Factors
- Qualifying APM Participants (QPs): $33.57 per relative value unit (RVU), marking a 3.77% increase from 2025.
- Non-Qualifying Practitioners: $33.40 per RVU, marking a 3.26% increase from 2025.
- Statutory Drivers: A 2.50% one-year statutory increase contributes to these rates, alongside updates to geographic practice cost indices and work RVUs.
Key Medicare Part B Adjustments
- Standard Monthly Premium: $202.90 (up from $185.00 in 2025).
- Annual Deductible: $283 (up from $257 in 2025).
- Therapy Services (KX Modifier Threshold): $2,480 for physical/speech therapy combined, and $2,480 for occupational therapy.
You can look up specific codes using the 2026 Medicare Fee Schedule Lookup.
Is CPT code 99213 still valid?
Yes, 99213 is a valid CPT code maintained by the American Medical Association (AMA).
Code Overview
- Definition: An office or other outpatient visit for the evaluation and management (E/M) of an established patient.
- Level: Commonly known as a "Level 3" office visit.
- Patient Status: The patient must be established, meaning they have seen the same provider (or another provider of the same specialty in the same group practice) within the past three years.
Billing Requirements
To report code 99213 properly, the encounter must meet one of two pathways on the date of service:
- Medical Decision-Making (MDM): Requires a medically appropriate history and/or examination, along with a low level of medical decision-making (such as managing one stable chronic illness or one acute, uncomplicated injury).
- Total Time: A total of 20 to 29 minutes is spent by the provider on the date of the encounter (including face-to-face and non-face-to-face work like chart review or documentation).
You can look up specific billing guidelines and relative value units (RVUs) using the AAPC Code Database.
What is the difference in reimbursement between CPT codes 99213 and 99214?
CPT code 99214 reimburses roughly 40% more than CPT code 99213, representing a national Medicare average difference of about $40 per visit.
Reimbursement Rates
- CPT 99213: Reimburses approximately $90 to $95 under national Medicare rates (level 3 low-complexity visit).
- CPT 99214: Reimburses approximately $126 to $148 under national Medicare rates (level 4 moderate-complexity visit).
- Note: Exact payment amounts depend on your geographic area, annual fee updates, and specific commercial insurance contracts.
Key Differences in Care and Time
The choice between these two codes depends on Medical Decision-Making (MDM) or total time spent on the date of service:
- CPT 99213: Requires low-complexity MDM (such as a stable chronic illness) or 20 to 29 minutes of total provider time.
- CPT 99214: Requires moderate-complexity MDM (such as multiple chronic conditions or prescription management) or 30 to 39 minutes of total provider time.
What is a level 4 office / outpatient visit in medical coding? 99214 & 99204 explained.
What are the reimbursement rates for CPT code 99213 in 2026?
The national average Medicare reimbursement rate for CPT code 99213 in 2026 is approximately $95.19 for non-facility settings.
Breakdown of 2026 Rates for CPT 99213
- Non-Facility (Office/Clinic): ~$95.19 nationally (varies by local geographic adjustment).
- Facility (Hospital/ASC): Lower than the non-facility rate, averaging around $55.10 to $72.00 depending on the specific locality.
- Commercial Payer Averages: Private insurance rates fluctuate widely, with sample national averages roughly spanning from $82.03 (Aetna) and $86.29 (UHC) to $91.46 (BCBS) and $101.25 (Cigna).
Key Factors Impacting Your Rate
- Conversion Factor: The 2026 Medicare Physician Fee Schedule conversion factor is $33.40.
- Geographic Adjustment (GPCI): Actual payments change based on your practice's specific geographic locality and local wage indices.
- Setting: Non-facility rates pay higher to account for practice overhead (staff, rent, equipment) compared to institutional facility settings.
How much does a 99213 office visit cost?
An office visit billed under CPT code 99213 typically costs between $100 and $250 without insurance, with a national average cash charge of $179.97. However, the exact amount you pay depends heavily on whether you have insurance, your provider's specific pricing, and your location.
Cost Breakdown by Payment Type
| Payment Type | Average Rate / Range | Notes |
|---|---|---|
| Cash / Uninsured | $100 – $250 (Avg: $179.97) | Many clinics offer a 20% to 40% discount for cash payments, dropping the cost to around $80 – $130. |
| Medicare Reimbursement | $91 – $95 | The standard national Medicare payment rate for a doctor's office setting. |
| Commercial Insurance | $82 – $102 | The contracted rate allowed by major insurers like BCBS, UnitedHealthcare, Aetna, and Cigna. You pay your copay or deductible toward this rate. |
| Medicaid Reimbursement | $46 – $92 | Varies widely depending on the state. |
What is a 99213 visit?
This code represents a Level 3 outpatient visit for an established patient (someone who has seen the same provider or group within the last 3 years). It is generally used for a routine check-in, a stable chronic condition (like well-controlled high blood pressure), or a minor acute illness (like a simple sprain). The doctor or clinician typically spends 20 to 29 minutes of total time on the date of the visit.
Potential Extra Fees
- Facility Fees: If your visit takes place in a hospital-owned outpatient clinic rather than an independent doctor’s office, the hospital may bill a separate "facility fee" that can drastically increase your out-of-pocket costs.
- Procedures & Tests: The prices above only cover the doctor’s time and evaluation. Any additional services performed during the visit—such as blood draws, rapid strep tests, or X-rays—will be billed under separate codes and add to the final total.
What are the current Medicare reimbursement rates by CPT code?
You can look up current Medicare reimbursement rates by CPT code using the official PFS Look-up Tool Overview provided by the Centers for Medicare & Medicaid Services (CMS).
How Medicare Rates Are Determined
- Relative Value Units (RVUs): Each CPT code has assigned RVUs for physician work, practice expense, and malpractice.
- Geographic Adjustment: RVUs are multiplied by Geographic Practice Cost Indices (GPCIs) based on your specific payment locality.
- Conversion Factor (CF): The adjusted total is multiplied by the annual conversion factor (around $33.40 to $33.57 depending on Alternative Payment Model participation).
- Facility vs. Non-Facility: Rates vary depending on whether the service is performed in an office (non-facility) or a hospital/facility setting.
- Standard Split: Original Medicare generally reimburses 80% of the approved amount, leaving the remaining 20% to coinsurance or secondary insurance.
You can also check estimated patient costs and facility pricing via the Procedure Price Lookup for Outpatient Services on Medicare.gov.
What are the Medicare rates for 2026?
The standard monthly premium for Medicare Part B in 2026 is $202.90, according to the Centers for Medicare & Medicaid Services.
Medicare Part A (Hospital Insurance)
- Monthly Premium: $0 for most people who have at least 10 years (40 quarters) of work history. It is $311 for those with 30–39 quarters, and $565 for those required to pay the full voluntary premium.
- Inpatient Hospital Deductible: $1,736 per benefit period.
- Daily Coinsurance (Days 61–90): $434 per day.
- Daily Coinsurance (Lifetime Reserve Days 91–150): $868 per day.
- Skilled Nursing Facility Coinsurance (Days 21–100): $217 per day.
Medicare Part B (Medical Insurance)
- Standard Monthly Premium: $202.90.
- Annual Deductible: $283.
- High-Income Surcharges (IRMAA): Beneficiaries with a modified adjusted gross income (MAGI) over $109,000 (individual) or $218,000 (joint) pay an additional monthly surcharge ranging from $81.20 to $487.00, making total monthly Part B premiums up to $689.90.
Medicare Part D (Prescription Drug Coverage)
- National Base Beneficiary Premium: $38.99 (average standalone plan premiums vary).
- Yearly Out-of-Pocket Maximum: $2,100.
- High-Income Surcharges (IRMAA): Adds an extra $14.50 to $91.00 per month depending on income tiers.
What is the Medicare reimbursement rate for 99214?
The national average Medicare reimbursement rate for CPT code 99214 in 2026 is $135.61 for a non-facility (private office) setting and $84.50 for a facility (hospital outpatient) setting.
Key Details for CPT Code 99214
- Service Description: Evaluation and management (E/M) service for an established outpatient or office patient.
- Time/Complexity Requirements: 30 to 39 total minutes on the date of the encounter, or moderate-complexity medical decision-making (MDM).
- Geographic Adjustments: Exact reimbursement amounts vary based on your local GPCI (Geographic Practice Cost Index) locality adjustment.