The short version
- 99213 is a level 3 office visit for an established patient. You get there one of two ways: low-complexity medical decision making, or 20 to 29 minutes of total time on the date of service. Either path on its own.
- History and exam no longer set the level. That changed in 2021. You document them as medically appropriate and they carry no scoring weight.
- 2026 Medicare pays about $95 nationally for 99213, non-facility, against a conversion factor of $33.40 for non-QP clinicians and $33.57 for QPs.
- Office visits were exempt from the 2026 efficiency adjustment that cut work RVUs 2.5% across roughly 7,700 codes — and the practice expense change moved money toward office-based care.
- The expensive habit is downcoding: billing 99213 when the note supports 99214, out of audit fear. The spread is about $40 a visit.
What 99213 actually requires in 2026
The rules changed in 2021 and a lot of guidance never caught up. History and exam no longer determine the level. You document them as medically appropriate, and they carry no scoring weight. What sets the level is medical decision making or time.
By MDM, 99213 is low complexity. In practice that usually means one stable chronic problem, or two minor ones, with straightforward management and low risk.
By time, 99213 is 20 to 29 minutes of total time on the date of service. Total time counts your pre-visit chart review, the visit itself, and the note, as long as it all happens that day. It does not count time on a different day, and it does not count staff time.
Hit 30 minutes and it is a 99214 on time alone, regardless of how simple the problem was.
What 99213 pays in 2026
Medicare’s 2026 conversion factor is $33.40 for clinicians who are not qualifying APM participants and $33.57 for those who are. Both took effect January 1, 2026, and both are up from 2025.
Two things worth knowing beyond the rate. The efficiency adjustment that cut work RVUs by 2.5% across roughly 7,700 codes does not touch office visits — CMS exempted the time-based E/M family, 99202 through 99215. And the practice expense change cut indirect PE for facility-setting work by half, which moves money toward office-based care. If your visits happen in your own office, 2026 is a better year than 2025 for this code family.
| Code | Level | Time (total, date of service) | MDM | 2026 national average |
|---|---|---|---|---|
| 99212 | 2 | 10-19 min | Straightforward | ~$59 |
| 99213 | 3 | 20-29 min | Low | ~$95 |
| 99214 | 4 | 30-39 min | Moderate | ~$136 |
| 99215 | 5 | 40-54 min | High | ~$192 |
Downcoding costs more than an audit
Here is what shows up in claims data that no coding manual will tell you: practices bill 99213 when the visit was a 99214, on purpose, because 99214 feels like audit bait.
It is the most expensive habit in a specialty office. The spread is about $40 a visit. A provider seeing 18 established patients a day who downcodes four of them is giving back roughly $40,000 a year — and the visits were documented correctly the whole time.
The fix is not to code more aggressively. It is to score the visit by MDM honestly and let the number land where it lands. Two stable chronic conditions, a medication adjustment, and a review of outside records is a 99214 in any auditor’s reading.
Two mistakes specialty offices make with 99213
Global period visits. A post-op visit inside the 10 or 90 day global is included in the surgical fee. Billing 99213 for a routine post-op check is not a level problem, it is a claim that should not exist. If the patient shows up in the global period with something unrelated, that is a different visit and it needs modifier 24, not a quietly submitted 99213. Our global period lookup has the day counts.
Same-day procedure visits. The established patient who comes in for a lesion check, gets evaluated, and leaves with a destruction or a biopsy has generated two billable services. The E/M needs modifier 25, and the documentation has to show the evaluation work stood on its own, separate from the procedure. Missing 25 is one of the most common denials we see in dermatology, and the fix is documentation discipline, not a coding change.
Five mistakes that turn a clean 99213 into a denial
- Using “20 or more minutes.” The range is 20 to 29. Over 29 is a 99214.
- Scoring history and exam as if it is still 2020. They do not set the level.
- Billing 99213 on a new patient. New patients are 99202 through 99205.
- Counting staff time, or a different day’s chart work, toward total time.
- Downcoding a documented 99214 to avoid attention.
Frequently asked questions
What is CPT code 99213?
A level 3 office or outpatient visit for an established patient, supported by either low-complexity medical decision making or 20 to 29 minutes of total time on the date of service. Either path qualifies on its own.
How much does 99213 pay in 2026?
About $95 nationally under Medicare, non-facility, before locality adjustment. The 2026 conversion factor is $33.40 for clinicians who are not qualifying APM participants and $33.57 for those who are, both effective January 1, 2026.
What is the difference between 99213 and 99214?
MDM complexity and time. 99213 is low-complexity MDM or 20 to 29 minutes; 99214 is moderate-complexity MDM or 30 to 39 minutes. Either path gets you there on its own. The payment difference is roughly $40 per visit.
How long does a 99213 visit have to be?
It does not have to be any particular length if you are coding on medical decision making. If you are coding on time, the range is 20 to 29 minutes of total time on the date of service, including your same-day chart review and documentation.
Can 99213 be billed with a procedure on the same day?
Yes, with modifier 25 appended to the E/M, and only when the evaluation was significant and separately identifiable from the procedure. Missing modifier 25 is one of the most common dermatology denials.
Is 99213 affected by the 2026 efficiency adjustment?
No. CMS exempted time-based services, including the E/M office visit family 99202 through 99215, from the 2.5% efficiency adjustment applied to roughly 7,700 other codes in 2026.
Is 99213 covered by Medicare?
Yes, when the visit is medically necessary and documented to the level billed. It is not a preventive service; annual wellness and preventive visits use their own code families.
Can 99213 be used for telehealth?
Yes, subject to the telehealth rules, place-of-service codes, and modifiers in force on the date of service. These have changed repeatedly since 2020, so confirm the current requirements before billing.
This article explains how these codes tend to get paid — it is not coding, billing, or legal advice. Some of the codes here are bundled into the main procedure, or fall into grey areas that vary by payer. Before billing anything in a grey area, confirm it with your own coding and compliance team and the current guidance from the American Academy of Dermatology (AAD), Medicare (CMS), and AMA CPT. When in doubt, don’t bill it.
