CPT Code 99213: What You Need To Know In 2024

June 17, 2024

CPT Code 99213: What You Need To Know In 2024

A frequently used code is CPT code 99213.

It’s an important one to use correctly so that you get paid what you deserve while giving your patients the best care possible!

Let’s check out CPT code 99213 in more detail, looking at its uses, requirements, and importance in patient care and billing.

And remember – you can always partner with a medical billing and coding company like us if you want to forget about this stuff and focus all your attention on your patients instead!


Key Points:

  • CPT code 99213 is an E/M code for office or outpatient visits with established patients requiring a low level of medical decision-making and/or 20 or more minutes of total time on the visit date.
  • It’s often used for follow-up visits for chronic conditions, post-operative visits in plastic surgery, routine check-ups, and managing new symptoms that do not require extensive workups.
  • Accurate use and documentation are key to avoid billing errors, claim denials, and financial losses.


What Is CPT Code 99213?

CPT code 99213 is an evaluation and management (E/M) code for office or other outpatient visits, typically used for established patients who require a low level of medical decision-making (MDM) and management.

If choosing the code based on time, the encounter involves 20 or more minutes of total time on the visit date.

99213 CPT Code Description: An office or outpatient visit with an established patient, focusing on evaluation and management involving a low level of medical decision making and/or requires the provider to spend 20 or more minutes in total on the visit on a single date.

CPT code 99213 is described as a “Level 3 Established Patient Office Visit.”

This means it is used for patients who have been seen by the provider previously and require a moderate level of care.

The visit usually involves:

  • A detailed history
  • A detailed examination
  • Medical decision-making of low complexity

What Is CPT Code 99213 Used For?

CPT code 99213 is commonly used in various scenarios, including:

  • Follow-up visits for chronic conditions like acne or psoriasis in dermatology.
  • Post-operative visits in plastic surgery to monitor recovery and manage complications.
  • Routine check-ups for ongoing treatments.
  • Assessing and managing new symptoms or conditions that do not require extensive workups.

The Importance of CPT Code 99213 in Patient Care & Billing

There are a lot of reasons why 99213 is important in your practice, especially so that you get properly reimbursed for your visits with established patients that require a low MDM with about 20 minutes of encounter time.

More reasons include:

  • Accurate Billing: Ensures that services are billed correctly, reducing the risk of claim denials.
  • Reimbursement: Facilitates appropriate reimbursement from insurance providers.
  • Compliance: Helps in maintaining compliance with healthcare regulations.
  • Patient Care: Supports thorough documentation, which is important for quality patient care and continuity.

CPT Code 99213 Requirements

CPT coding used to be a bit different before 2021.

You used to need the three key components of MDM, a medical history, and a detailed examination of the patient’s condition, but there is now a much greater emphasis on MDM and/or encounter time, meaning you can code 99213 for based on how long your visit with an established patient is or how complex the MDM was.

This also affected codes like 99214, 99204, 99205, and many more!

With a heavy emphasis on MDM and encounter time, criteria to code for 99213 in 2024 is:

  • A low level of medical decision-making
  • ~20 minutes of patient visit time
  • A comprehensive patient examination

99213 CPT Code Reimbursement Rates in 2024

The Medicare reimbursement rate for CPT code 99213 in 2024 is $90.88.

It’s not as high as something like 99214 or 99215 due to its low MDM requirements and low encounter time requirements, yet it’s important not to miss out on opportunities where you can code for 99213.

Common Mistakes to Avoid in Billing CPT Code 99213

Billing errors can lead to claim denials and financial losses – not good!

Common mistakes to avoid include:

  • Not The Right Documentation: Failing to provide how long you spent with the patient, what you did with them, etc.
  • Upcoding or Downcoding: Misrepresenting the level of service provided.
  • Incorrect Use of Modifiers: Not using appropriate modifiers when necessary.
  • Patient Status: Using 99213 as a new patient code instead of established ones.

CPT Code 99213 vs. 99214 vs. 99215

Understanding the differences between CPT codes 99213, 99214, and 99215 is key for accurate billing and not missing out on cash.

The main difference between the 3 is the complexity of MDM and encounter time:

  • 99213: Moderate level of care for established patients with detailed history and examination, and low complexity decision-making.
  • 99214: Higher level of care with a more comprehensive history and examination, and moderate complexity decision-making.
  • 99215: Highest level of care with extensive history and examination, and high complexity decision-making.

Here is a chart summarizing the key differences:

CodeHistory/ExamMDMEncounter Time (minutes)Reimbursement Rate (2024)
99213Medically appropriate history and/or examinationLow20$90.88
99214Medically appropriate history and/or examinationModerate30-39$128.16
99215Medically appropriate history and/or examinationHigh40+$180.42
From CMS

Conclusion

CPT code 99213 is a big component of medical billing in plastic surgery and dermatology practices.

Understanding its proper use, requirements, and importance can significantly improve billing accuracy, reimbursement rates, and overall patient care.

At The Auctus Group, we are committed to providing the best medical billing and coding services tailored to the unique needs of plastic surgery and dermatology clinics.

Our expertise and dedication to customer service ensure that your practice thrives financially and operationally.

Send us a message or give us a call and we’d be happy to talk about how we can help out with your coding – and how to make you more money!

FAQs

What is CPT code 99213 used for?

CPT code 99213 is used for an established patient office or other outpatient visit that requires a medically appropriate history and/or examination and low level of medical decision-making along with 20 minutes of encounter time.

What is the difference between CPT code 99213 and 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 level of service is 99213?

CPT code 99213 represents a Level 3 established patient office visit, which involves low complexity in medical decision-making.

How much is 99213 reimbursement?

Reimbursement for CPT code 99213 in 2024 is currently $90.88 for Medicare.

Is 99213 preventive?

No, CPT code 99213 is not classified as a preventive service. It is used for addressing specific medical issues during an established patient office visit.

Is 99213 a telehealth code?

CPT code 99213 can be used for telehealth services if the visit meets the criteria for a low level of medical decision-making and is conducted via an approved telehealth platform.

Who can bill for 99213?

Physicians and qualified healthcare professionals who provide care to established patients can bill for CPT code 99213, provided the services meet the required documentation and complexity criteria.

Is CPT 99213 covered by Medicare?

Yes, CPT code 99213 is generally covered by Medicare, as long as the visit meets the necessary medical necessity requirements and documentation standards.

What qualifies for a 99214?

A visit qualifies for CPT code 99214 when it involves a moderate level of medical decision-making, more extensive history and examination, and typically requires at least 30 minutes of the provider’s time.

What are the time guidelines for 99213?

The typical time associated with CPT code 99213 is approximately 15-20 minutes, although time alone is not the sole determining factor; the visit must also involve low complexity medical decision-making.

Does 99213 need a modifier?

Modifiers may be necessary for CPT code 99213 under certain circumstances, such as when billing for telehealth services or when other procedures are performed on the same day (e.g. Modifier 25). The specific modifier depends on the situation and payer requirements.

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