CPT Code 99213: Office Visit, Established Patient (Low Complexity)
Reviewed against AMA CPT and CMS guidance. See sources.
What is CPT 99213?
CPT 99213 is an office or outpatient visit for an established patient with low medical decision making, or at least 20 minutes of total time on the date of the visit. In behavioral health, it fits visits where overall decision making is low; managing a prescription medication counts as moderate risk. Same-day psychotherapy is added with 90833, 90836, or 90838.
Evaluation and management (E/M) office visit for an established patient with low medical decision making. In behavioral health, used by psychiatric prescribers for follow-ups where overall decision making is low.
Time Requirements
Low medical decision making, or at least 20 minutes of total clinician time on the date of the encounter. If psychotherapy is billed the same day, psychotherapy time cannot count toward E/M time.
Modifiers
| Code | Description |
|---|---|
| 25 | Significant, separately identifiable E/M service on the same day as a procedure. Payer requirements vary when billing E/M with a psychotherapy add-on. |
| 95 | Synchronous audio-video telehealth. Many payers also require a telehealth place of service code (02 or 10). |
| 93 | Synchronous audio-only service, where the payer allows audio-only care. |
Billing a session by video or phone? See telehealth modifiers 95, 93, GT and POS 02 vs 10.
When to Use
- Follow-up for a stable problem where data reviewed and risk are also low
- Brief evaluation by a prescriber with low decision-making complexity
- Follow-up visits where the overall medical decision making is low (note that managing a prescription medication, even without a change, counts as moderate risk)
- With a psychotherapy add-on (90833, 90836, 90838) when both services are provided and documented separately
When Not to Use
- Initial evaluations: use 90791 or 90792, or a new-patient E/M code (99202 to 99205) when appropriate
- Moderate decision-making complexity: use 99214
- Therapy by clinicians who do not bill E/M: use 90832 to 90837
- On the same day as 90791 or 90792 by the same clinician
What to Document for CPT 99213
- Problems addressed and their status
- Data reviewed (records, labs, outside information)
- Medication decisions and risk
- Total time, if the level is chosen by time
- If psychotherapy was added, a separate psychotherapy section with its own minutes
Common Denial Reasons
- Documentation does not support the level of medical decision making
- Time-based level that counts psychotherapy minutes toward E/M time
- Psychotherapy billed as 90832 to 90837 instead of an add-on code on the same day
- Total time not documented when the level is chosen by time
Payer Notes
E/M level is chosen by medical decision making or total time on the date of the encounter. When psychotherapy is added, any time-based E/M level must leave out psychotherapy minutes. Modifier 25 requirements for E/M with a psychotherapy add-on vary by payer.
ICD-10 diagnosis codes
Every claim pairs the CPT code with the diagnosis the clinician documented. See the mental health ICD-10 code reference or a condition guide:
Related Codes
Frequently Asked Questions
When should I use 99213 vs 99214 for medication management?
Use 99213 when overall decision making is low. Use 99214 when decision making is moderate, which requires two of three elements at the moderate level: problems, data, and risk. Prescription drug management, including continuing a medication, is moderate risk.
Can I bill psychotherapy with 99213?
Yes, by adding psychotherapy add-on 90833 (16 to 37 minutes), 90836 (38 to 52 minutes), or 90838 (53 minutes or more), when the E/M is significant and separately identifiable and psychotherapy minutes exclude E/M time.
What counts toward the 20 minutes?
Total time by the billing clinician on the date of the encounter, including face-to-face and non-face-to-face work such as reviewing records, ordering, documenting, and coordinating care. It excludes time spent on separately reported services such as psychotherapy.
Can therapists bill 99213?
Generally no. E/M codes are billed by physicians and other clinicians whose license and payer enrollment allow E/M services, such as nurse practitioners and physician assistants.
Sources: American Medical Association (AMA), CPT Professional codebook: code descriptors, psychotherapy time rules, and add-on code guidance. Centers for Medicare & Medicaid Services (CMS): Medicare Physician Fee Schedule and National Correct Coding Initiative (NCCI) policy.
- AMA: CPT overview
- CMS: National Correct Coding Initiative (NCCI) edits
- CMS Medicare Coverage Database: Billing and Coding, Psychiatry and Psychology Services (A57480)
- CMS: Physician Fee Schedule relative value files
- CMS MLN901705: Telehealth and Remote Monitoring (PDF)
Payer rules vary. Confirm coverage, time, modifier, and documentation rules with each payer before billing. This page is general education, not billing or legal advice.
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