If you’ve spent any time in a physician’s office, whether as a provider, billing team, or practice manager, you’ve seen CPT code 99213 more times than you can count. It’s one of the most commonly billed office visit codes in the United States. In many outpatient practices, it quietly makes up a large portion of daily encounters.
But despite how often it’s used, the 99213 CPT code is frequently misunderstood. Some providers default to it out of habit. Others undercode out of caution. And sometimes it’s billed incorrectly simply because no one fully explained what truly qualifies.
Let’s slow things down and look at low-level medical decision-making evaluation and management (E/M) CPT code in a practical, real-world way, what it represents, when it applies, how to document it correctly, and how to avoid common compliance mistakes
What Is CPT Code 99213?
CPT 99213 is defined as an office or other outpatient visit for the evaluation and management of an established patient.
An established patient is someone who has received professional services from the same physician, or another physician of the same specialty in the same group practice, within the past three years. So right away, 99213 is not for new patients. New patient visits use a completely different code range from 99202–99205.
In simple terms, the evaluation and management (E/M) CPT code represents a routine but medically necessary follow-up visit. It’s the kind of appointment where the provider evaluates a condition, makes clinical decisions, and adjusts or continues treatment, but without high complexity or high risk.
The evaluation and management code is selected based on either
- Medical Decision Making (MDM)
- Total time spent on the date of the encounter
History and exam are still documented when medically appropriate, but they no longer determine the code level.
This shift was meant to better reflect the provider’s thinking and actual work, not how many boxes were checked in the note.
Medical Decision Making at the 99213 Level
When billing 99213 based on MDM, the visit must meet the criteria for low-level medical decision-making.
MDM is determined by evaluating three elements:
- The number and complexity of problems addressed.
- The amount and complexity of data reviewed,
- The risk of complications or morbidity associated with patient management.
To qualify for a low-level medical decision-making evaluation and management (E/M) code, at least two of these three elements must meet the criteria.
At this level, the problems addressed are typically straightforward. A stable chronic illness, such as controlled hypertension or well-managed diabetes,s often qualifies. An acute, uncomplicated illness, like sinusitis, a urinary tract infection, or mild bronchitis, also fits comfortably within this category. The provider is evaluating and managing the condition, but the clinical picture is stable and not worsening.
The data reviewed at this level is limited but meaningful. The provider may review recent laboratory results, order basic diagnostic tests, or examine prior notes. The analysis is important but not extensive.
Risk is often the deciding factor. At the 99213 level, risk is considered low. Prescription drug management frequently supports this level of risk. For example, continuing or adjusting a blood pressure medication may qualify as low risk, provided there are no complicating factors.
When two of these three elements align at the low level, the visit meets the MDM threshold for 99213
How to Use the Evaluation & Management Code for Time-Based Billing?
Alternatively, providers may select a low-level medical decision-making evaluation and management (E/M) code based on the total time spent on the date of service.
The required time range is 20 to 29 minutes. This includes all work performed by the reporting provider on that same day. Time may involve reviewing medical records before the visit, face-to-face interaction with the patient, counseling and education, ordering medications or tests, documenting the encounter, and coordinating care.
It is important to understand that only the provider’s time counts. Time spent by nurses or medical assistants does not apply. Additionally, work performed on different dates cannot be included.
When billing based on time, documentation should clearly state the total minutes spent and describe the activities performed. Precision in recording time is essential, especially in the event of an audit.
What Is the Difference Between 99213 and 99214?
One of the most common questions in outpatient coding is, Is this a 99213 or a 99214?
Here’s a practical way to think about it. If the condition is stable, uncomplicated, and low risk, you’re likely in 99213 territory.
If the condition is worsening, involves multiple chronic illnesses, requires medication adjustments with increased risk, or involves more extensive data review, you may be looking at 99214.
For example:
- Stable diabetes with no medication changes likely 99213
- Uncontrolled diabetes requiring insulin adjustment and lab analysis, likely 99214
It’s not about how long the note is. It’s about how complex the decision-making truly is.
Common Evaluation & Management Coding Mistakes
Because CPT code 99213 is used so often, it tends to get extra attention from payers. One common issue is not intentional use. It is due to frequent occurrence that it become habit. Some providers get comfortable selecting evaluation and management codes for most established patient visits because it feels like the safe middle ground. Over time, that routine can become automatic coding without fully considering the visit’s actual complexity or the medical decision-making involved.
The problem is that insurance companies closely track medical billing patterns.. If a provider bills 99213 for nearly every established patient encounter, it can raise questions during data analysis. That doesn’t automatically mean something is wrong, but it can trigger reviews or audits. Taking a moment to match the accurate code to the documentation and the true level of care provided helps protect both compliance and claim denial.
Another issue is insufficient documentation. Although history and exam elements no longer determine the level, the medical decision-making process must still be clearly documented. The note should reflect the condition’s status, any data reviewed, and the management plan.
Regular internal audits or outsourcing your revenue cycle to a professional billing team, like Liberty Liens, is a best practice for identifying patterns and correcting coding errors and weaknesses before external review occurs.
Documentation Tips for Evaluation & Management (E/M) Code
When it comes to CPT code 99213, documentation does not have to be long. The goal isn’t to write a novel. The goal is to show your clinical thinking in a way that supports low-level medical decision making (MDM) or the required 20–29 minutes of total time.
Think of your note as telling a short but complete story:
What problem did the patient have today? What did you review? What did you decide? Why?
Below are practical, real-world documentation tips that make evaluation and management (E/M) CPT code defensible
1. Clearly State the Status of Each Problem
One of the most common documentation gaps is failing to describe whether a condition is stable, improving, worsening, or uncontrolled. If you’re addressing diabetes, asthma, depression, or another chronic illness, always document the current status, not just the diagnosis.
2. Document What You Reviewed
If you reviewed labs, imaging, or prior notes, document it clearly. Even a limited data review helps support low-level medical decision-making evaluation and management (E/M) CPT code and improve your revenue cycle.
3. If Billing Based on Time, Document It Precisely
If you’re selecting 99213 based on time, you must document the total minutes spent on the date of service. Without a total time clearly stated, the insurer cannot credit time-based billing.
Strong documentation doesn’t have to be complicated. It just needs to reflect your clinical thinking in a clear, specific, and honest way.
Why 99213 Matters in Healthcare Practices
CPT code 99213 captures the essence of outpatient medicine. It reflects the continuity of care that keeps chronic illnesses controlled and acute conditions from worsening. It represents preventive oversight, medication monitoring, and steady physician engagement.
Though it may not seem as complex as higher-level visits, it plays a vital role in patient outcomes and practice sustainability. When properly documented and coded, it ensures fair reimbursement while maintaining compliance with CMS and payer guidelines.
Final Thoughts
The low-level medical decision-making evaluation and management (E/M) CPT code
is more than just a routine billing entry. It is a carefully defined level of service that requires clear documentation, sound clinical judgment, and familiarity with current E/M guidelines.
To use it correctly, providers and coders must understand the distinction between low and moderate complexity, the time requirements for reporting, and the importance of supporting medical necessity in every note.
When approached with accuracy and consistency, the low-level medical decision-making evaluation and management (E/M) code becomes a reliable and compliant representation of the everyday care delivered in outpatient practices across the United States.
