99213 — Office Visit, Established Patient (Low Complexity)
Evaluation and Management (E/M) office visit for an established patient with low medical decision-making complexity. In behavioral health, this is commonly used by psychiatrists and prescribers for brief medication management follow-ups when the clinical situation is straightforward.
Time Requirements
Typically 15-29 minutes total time OR low complexity medical decision making. Time-based billing requires total time on the date of encounter.
Modifiers
| Code | Description |
|---|---|
| 25 | Significant, separately identifiable E/M service on the same day as a procedure or therapy code. |
| 95 | Synchronous telemedicine service. |
When to Use
- Routine psychiatric medication management follow-up (stable patient)
- Brief medical evaluation by a prescriber with straightforward decision making
- Follow-up visit where medication is continued without changes
- When combined with therapy — use modifier 25 on the E/M code
When Not to Use
- Initial evaluations — use 90791 or 90792
- Complex medication changes or multiple medication adjustments — use 99214
- Therapy services by non-prescribers — use therapy codes
- When the visit complexity warrants 99214
Common Denial Reasons
- Documentation does not support the level of medical decision making
- Upcoded (99214 documentation submitted but 99213 complexity)
- Missing modifier 25 when billed same day as therapy code
- Time-based billing without total time documentation
Payer Notes
Under the 2021 E/M guidelines, complexity is based on medical decision making (MDM) or total time. For behavioral health prescribers, document the number of diagnoses, medications reviewed, and risk level. Can be billed same-day with therapy codes using modifier 25 if both services are distinct.
Frequently Asked Questions
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