CPT 99213 is an evaluation and management code of an established patient. It is one of the highly used E&M code across board. Hence it is necessary to know more about this code. We have tried including maximum details of CPT 99213 briefly in this topic.
Location of CPT 99213 in CPT coding manual:
CPT or current procedural terminology in medical coding is used to track services and procedures furnished by physician, non-physician practitioners, hospitals, outpatient service and allied health professionals.
If you take a look at CPT book, it has 3 categories in which category 1 (5 digit numerical codes) is further divided into 6 sections. Those are evaluation and management (E&M), anaesthesia, surgery, radiology, pathology and laboratory services, medical services and procedures.
Section E&M includes codes ranging from 99202 to 99499. This clearly explains the place of CPT 99213 in CPT book.
CPT 99213 Code Description:
Office or other outpatient visit E&M code of established patient requires medically appropriate history and/or exam with MDM of low level. When using time for code selection, it requires total of 20-29 minutes on the same date of service.
CPT codes 99202 – 99205 is used for new patient (visiting same physician or physician group practice for the first time in last 3 years) and CPT 99211 – 99215 is used for established patient (there are visits performed within past 3 years to same physician or physician group practice) in an office or out-patient setting of any qualified healthcare practitioner. These codes can be used in telemedicine also as per payer guidelines. Reimbursement rates for CPT codes differ in different states.
99201 – Deleted CPT effective from Jan 01, 2021
Selection of CPT 99213
It is important to know the criteria’s on selecting CPT 99213 from medical record. There are 2 ways to select the code – based on MDM and based on time.
1) Based on MDM:
In the below table it has to meet atleast one criteria from any 2 sections for CPT 99213.
|Number and complexity of problem (Low)||Amount and/or complexity of data (Limited)-Meet any 1 category||Risk of complication and/or morbidity or mortality|
|2 or more self-limited or minor problems
1 stable chronic illness
1 acute uncomplicated illness or injury
|Category 1: Tests and documents
Any combination of 2 from following
o Review of prior external note from each unique source
o Review of result of each unique test
o Ordering of each unique test
Category 2: Assessment requiring independent historian
|Low risk of morbidity from additional testing or treatment|
2) Based on Time:
A total of 20-29 minutes (apart from the time of other procedures separately billed, travelling time and general teaching time) is required to capture CPT 99213
Place of service (POS):
Place of service (POS) represent the place or setting where the service was rendered. Below is the list of POS allowed with CPT 99213
|5||Indian health service free standing facility|
|6||Indian health service provider based facility|
|7||Tribal 638 free standing facility|
|8||Tribal 638 provider based facility|
|17||Walk-in retail health clinic|
|19||Off campus outpatient hospital|
|20||Urgent care facility|
|22||On-campus outpatient hospital|
|24||Ambulatory surgical center|
|26||Military treatment facility|
|50||Federally qualified health center|
|53||Community mental health center|
|57||Non-residential substance abuse treatment facility|
|62||Comprehensive outpatient rehabilitation facility|
|65||End stage renal disease treatment facility|
|71||Public health clinic|
|72||Rural health clinic|
A healthcare professional uses modifier with a CPT to indicate that the particular service is modified or altered in some or the other way. Below are the modifiers allowed to use with CPT 99213.
- 25 – Most commonly used modifier. It is used when there is an additional service or procedure performed on the same day.
- 24 – This is used in postoperative period to specify the E&M service performed is unrelated to the surgery undergone.
- 57 – When there is a major (90 day global period) surgery is done on the same or next day, we need to use this modifier with E&M to indicate the decision for surgery
- 27 – This is to indicate that there are multiple E&M services performed on same day.
- 95 or GT – Telemedicine modifiers
Tips for coding CPT 99213
- Confirm the patient is new or established as the first step.
- This code can be used for telemedicine as per payer specification of either using place of service 02 or with modifier GT or 95
- Make sure to code to the correct place of service.
- Refer previous billing data to see if the patient is in postoperative or not.
- Remember the changes made in Jan 01, 2021 of selecting E&M based on either time or MDM whichever can pay maximum reimbursement rate to the physician.
We will see few examples.
CPT 99213 Example 1:
HPI: Jerome is a 58 year old patient with known history of osteoarthritis bilateral knee. He is using Tylenol to control the pain. Today he is in the clinic stating the pain in right knee is not controlled even with Tylenol.
ROS: Musculoskeletal – Present – Pain on right knee. Not present – stiffness, sores, and rash.
Physical Exam: Notes mild swelling on right knee compared to left. There is no erythema found.
Plan: Prescribed ibuprofen 400 mg and advised to return next week if no improvement.
Coding for this scenario would be:
99213 – M17.0 (bilateral osteoarthritis)
Note: Here the code selected is CPT 99213 as it met 2 sections in MDM table, 1 stable chronic illness (osteoarthritis) in first column and low risk in 3rd column. There is no data point to select in this scenario. Time spent on the visit is not mentioned, hence coded only based on MDM.
CPT 99213Example 2:
HPI: 28 year old Mary is here in the clinic for nasal congestion and running nose from past 3 days. He has non-productive cough as associated symptom.
Physical Exam: Noted vitals (Temp-98 degree Fahrenheit, BP – 110/74 mmHg). There is no acute distress. Oropharynx is clear without erythema or exudates. Lung exam does not show any abnormality.
Assessment: Common cold. Physician suggested taking Tylenol if needed. Total of 22 min was spent today including discussion with the patient.
Coding for this scenario would be:
99213 – J00 (common cold), R05 (cough)
Note: In this scenario as per MDM the code section goes to CPT 99212 based on a straightforward MDM, but CPT 99213 is selected as per time (20 to 29 min). From Jan 01, 2021 physician has to get maximum payment based on either MDM or time whichever is high.