In the world of medical billing and coding, five digits and their accurate usage decide if you will get reimbursement for the care you offered to your patient or if it will be recorded as another write-off in your ledger. We are talking about CPT codes that effectively capture the services and procedures you render to your patients.
From over 11,000 of these standardized codes, today, our attention is on CPT 99213. We want to provide you with a comprehensive understanding of its description, real-world application, and billing considerations, with the hope that it will lead to successful reimbursements.
So, are you ready to conquer CPT code 99213 with confidence?
What is CPT Code 99213?
The Current Procedural Terminology (CPT) code 99213 reports a level 3 evaluation and management (E/M) visit during which an established patient meets the provider in an office or outpatient setting for 20 or more minutes. The visit includes low-level medical decision-making after relevant information gathering (e.g., patient’s medical history), physical examinations, and a review of the current treatment plan.
Like all the other CPT codes, 99213 is also maintained by the American Medical Association (AMA). It is part of the standardized coding system that was created to ensure effective communication between healthcare providers and medical insurance payers.
To comprehend CPT code 99213 in its entirety, you must first grasp the following three concepts:
Evaluation and Management (E/M) Visits
E/M visits or services can be defined as routine office visits, follow-up appointments, emergency department visits, complex consultations, or preventive exams during which the healthcare provider diagnoses and treats illnesses or injuries. These can range from straightforward meetings to urgent assessments and treatments for highly complicated cases.
Low-Complexity Medical Decision-Making
Low-complexity medical decision-making typically occurs when a patient with a stable chronic illness (disease or disorder) or an acute but uncomplicated injury visits the provider’s office for a follow-up assessment or treatment adjustment. As the patient’s condition is otherwise stable, the provider spends 20-29 minutes with the patient, asking questions about his current condition and making changes to the treatment plan if needed.
Established Patient
Any patient who has received medical services from the same provider or another healthcare practitioner from the same specialty, working at the same group practice, within the last three years is identified as an established patient.
Scenarios Where CPT Code 99213 is Applicable
There could be many reasons for an established patient to visit the healthcare provider’s office or an outpatient hospital/clinic without undergoing extensive examinations or treatment procedures. In this section, we will discuss some applicable scenarios for CPT code 99213 to help you understand its appropriate usage in the real world.
Follow-up Visit of a Patient with Fractured Arm
Assume that a patient fractured his arm a month ago. Back then, the orthopedist and his team realigned the patient’s broken bone and plastered the arm with a cast to immobilize it and promote healing. Four weeks later, the patient visits the orthopedist for a follow-up appointment and to check for signs of recovery.
The orthopedist will assess the patient’s current condition by asking about the level of pain, checking the movement of the hand, and evaluating other symptoms like swelling or rashes. He may change the patient’s medications or prescribe additional drugs to expedite healing or reduce discomfort. Since this follow-up visit with an established patient involves low-complexity medical decision-making, the orthopedist will report it with CPT code 99213.
Routine Check-up of a Diabetic Patient
Diabetes is a chronic disease that requires regular monitoring and management. Now, consider that a patient with diabetes visits his primary care physician for a routine check-up. During this visit, the provider will ask the patient about his overall health, such as difficulties with weight management or open wounds, and proceed to check his blood sugar levels. The provider may conduct other physical examinations, such as measuring the patient’s blood pressure and weight, to rule out other related conditions like hypertension and obesity.
Again, low-level medical decision-making is required to manage the established patient’s diabetes and suggest the appropriate treatment plan. Hence, CPT code 99213 will be reported.
Management Visit for Medication Side Effects
CPT code 99213 can also be reported when an established patient visits his healthcare provider to discuss and treat side effects caused by the medicines that were prescribed to him. For example, a patient diagnosed with depression meets his clinical psychologist to reduce the side effects of his current anti-depressants. He complains of weight gain, insomnia, and excessive sweating.
After assessing the patient’s condition, the psychologist lowers the dosage of the current medicines and revises the diet plan to cancel out the side effects. Since this was a level 3 E/M visit and involved low-complexity medical decision-making, the psychologist will code it with CPT 99213.
X-Ray Interpretation for Asthma Monitoring
Like diabetes, asthma is a chronic ailment that affects a person’s lungs, making it harder to breathe. Therefore, a person with severe asthma requires constant monitoring and training to keep the symptoms in check.
Now, consider that a patient with severe asthma visits the hospital’s OPD to meet his specialist after he was advised to get a chest X-ray. The patient presents himself with the imaging reports for the specialist to interpret them. The specialist views the chest X-rays and informs the patient about visible signs of pulmonary hyperinflation. He revises the patient’s care plan to include the necessary medicines for airway expansion and teaches the patient breathing techniques to manage his wheezing.
This follow-up visit for X-ray interpretation will be reported with CPT code 99213 to indicate low-complexity medical decision-making for an established patient.
Cold Sores Diagnoses and Treatment
Imagine a patient with a history of lupus (an autoimmune disease) visiting the healthcare provider’s office and complaining of visible blisters around her mouth and on her lips. The provider examines the blisters and diagnoses them as cold sores (a contagious herpes simplex virus infection). He informs the patient that she developed the infection due to her weakened immune system. As a treatment method, the provider prescribes her antiviral creams and oral medicines.
This E/M visit will be reported with the CPT code 99213 as the diagnosis and treatment of a new illness did not require extensive workup.
Things to Consider While Billing CPT Code 99213
Just knowing when to report CPT 99213 is not enough if you are seeking accurate reimbursement against this code. You must also understand that medical billing is an intricate process and includes several steps. Each step of the process should justify your selection of CPT code 99213 to make your claim acceptable in the eyes of the insurance payers.
Below, we have mentioned a few key aspects you must consider while reporting CPT code 99213.
Tick All the Components of CPT Code 99213
You must ensure that all three components of CPT code 99213 are covered.
- Recoding the Patient’s Medical History
First, you must record the established patient’s extended problem-focus history. This includes noting down the patient’s chief complaint (CC), like follow-up on hypertension, asking about the history of the present illness, reviewing the present issue, and inquiring about past, family, and social history related to the problem.
- Examining the Patient’s Current Condition
The second component of CPT code 99213 includes an expanded problem-focused examination where the provider checks the patient’s vital signs and assesses the affected body part or organ(s). For example, it may involve a cardiovascular or respiratory exam, depending on the patient’s primary complaint.
- Medical Decision-Making
The third and most important component of CPT code 99213 is medical decision-making and the level of complexity encountered in the process. So, the decision-making will be marked “low-complexity” if the number of diagnoses or the treatment options are few (one or two), limited data is assessed, and the patient’s condition is low-risk (e.g., a stable chronic condition).
Maintain Complete Documentation
You must maintain and submit complete documentation to prove the medical necessity of this E/M service rendered to an established patient in an office or outpatient setting. From the patient’s medical history to the latest treatment plan, everything should be accurately documented and submitted to the insurance payer with the claim form.
Ensure Time-Based Coding
While reporting CPT code 99213, you should provide a breakdown of the total time spent with the patient. For example, if a 20-minute E/M visit includes 12 minutes of training, such as learning breathing exercises for asthma management, you should properly document this fact.
Use Modifier if Needed
Modifiers provide greater insight into the circumstances and complexities that affect care delivery on that particular day. Consider appending appropriate modifiers with CPT code 99213 to explain to the insurance payer how, where, and why a service was performed. For example, you can use modifier 25 to indicate that this E/M service was separate and distinct from another procedure or service performed on the same day.
The Takeaway
99213 is one of the most frequently used CPT codes in outpatient clinical settings. Its accurate usage in the claim form and supporting billing best practices, like maintaining and submitting complete documentation, can have a significant impact on the reimbursement time and rate. As of January 1, 2025, the current Medicare reimbursement rate for CPT code 99213 is between $63 and $110, depending on the MAC locality and facility.
You must remember that CPT code 99213 is valid when the E/M service is rendered to an established patient in an office or outpatient setting and involves low-complexity medical decision-making. Moreover, you must cover the three essential components of this visit – recording the patient’s focused history, conducting a focused examination, and making a low-complexity medical decision, to justify using CPT code 99213.
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