CPT 99213 is the code for a level 3 office or outpatient visit with an established patient. It requires a medically appropriate history and/or exam plus either low-level medical decision making (MDM) or at least 20 minutes of total practitioner time on the date of the visit. In 2026, Medicare's national rate is $95.19 in an office and $57.45 in a facility.
CPT 99213 description
The AMA's official descriptor covers an office or other outpatient visit for an established patient that requires a medically appropriate history and/or examination and a low level of MDM. When total time is used to pick the level, 20 minutes must be met or exceeded.
An established patient has received professional services from the same physician, or another physician of the same specialty and subspecialty in the same group, within the past three years. Everyone else is new and gets 99202–99205.
Two ways to qualify: MDM or time
Since 2021, history and exam no longer set the level. You choose the method that best supports the visit.
Option 1: Low MDM. Meet or exceed two of the three elements below.
MDM element | What "low" looks like for 99213 |
|---|---|
Problems addressed | 2+ self-limited or minor problems; or 1 stable chronic illness; or 1 acute, uncomplicated illness or injury; or 1 stable acute illness |
Data reviewed and analyzed | Limited: any 2 of reviewing an external note, reviewing a unique test result, or ordering a unique test; or an assessment that needs an independent historian |
Risk of patient management | Low risk of morbidity from testing or treatment, such as OTC drugs, physical therapy, or minor surgery without risk factors |
Option 2: Total time. Count all practitioner time on the date of the encounter, face-to-face or not: reviewing records, examining, counseling, ordering, documenting, and coordinating care. Don't count clinical staff time or separately billed services. For 99213, the total must reach 20 minutes. At 30 minutes, 99214 applies.
Scored examples
Hypertension follow-up. BP is controlled; the physician refills lisinopril. Problems: 1 stable chronic illness (low). Data: none (minimal). Risk: prescription drug management (moderate). Two elements reach at least low, so the visit is 99213.
Uncomplicated UTI. The provider orders a urinalysis and prescribes an antibiotic. Problems: acute uncomplicated (low). Data: one test ordered (minimal, because the result review is included with the order). Risk: prescription (moderate). Result: 99213.
Two minor problems. A patient has a cold and an insect bite; the provider recommends OTC treatment. Problems: 2 self-limited (low). Risk: OTC drugs (low). Result: 99213.
Not a 99213. A patient with diabetes and hypertension, both stable, gets a medication adjustment. Problems: 2 stable chronic illnesses (moderate). Risk: prescription (moderate). Two moderate elements make this 99214.
99212 vs 99213 vs 99214 vs 99215
Code | MDM level | Time threshold | Typical problem | 2026 Medicare (office) |
|---|---|---|---|---|
99212 | Straightforward | 10 min | 1 self-limited problem | — |
99213 | Low | 20 min | 1 stable chronic illness | $95.19 |
99214 | Moderate | 30 min | 2+ stable chronic illnesses, or 1 worsening | $135.61 |
99215 | High | 40 min | Severe exacerbation or threat to life | $192.39 |
The jump from 99213 to 99214 is about 42%. That gap is why payers and the OIG watch level distribution closely, in both directions: upcoding brings recoupments, and habitual downcoding leaves earned revenue on the table.
99213 reimbursement in 2026
Medicare pays 99213 from three relative value units multiplied by the 2026 conversion factor of $33.4009:
Setting | Work RVU | Practice expense RVU | Malpractice RVU | Total RVU | National payment |
|---|---|---|---|---|---|
Office (non-facility) | 1.30 | 1.46 | 0.09 | 2.85 | $95.19 |
Facility | 1.30 | 0.33 | 0.09 | 1.72 | $57.45 |
Local rates shift with the Geographic Practice Cost Index, from about $85 in Arkansas to $113 in Alaska. Commercial payers often pay a multiple of Medicare, and Medicare patients owe 20% coinsurance after the Part B deductible.
What changes for 99213 in 2027
CMS released the CY 2027 Physician Fee Schedule final rule on November 4, 2026. Three changes hit 99213 on January 1, 2027:
Lower conversion factor. It drops 2.31% to $32.63 for clinicians outside advanced APMs, and to $32.95 for qualifying APM participants. If 99213's RVUs held at 2.85, the office rate would land near $93; check the final RVU file before updating fee schedules.
G2211 becomes modifier B1. The visit-complexity add-on is replaced by modifier B1 on the E/M code, which raises the visit payment by 16%. Clinicians in Shared Savings Program ACOs or the LEAD Model can use B2 instead for a 32% increase.
Modifier 25 same-day cut. When an E/M with modifier 25 falls on the same day as a 0-day global procedure by the same physician (or same specialty in the group), Medicare pays the higher service in full and the other at 80%.
Medicare telehealth flexibilities run through December 31, 2027, so 99213 can still be billed for qualifying telehealth visits with the right place of service and modifiers.
Modifiers used with 99213
Modifier | When to use it |
|---|---|
25 | A significant, separately identifiable E/M on the same day as a procedure |
24 | An unrelated E/M during a postoperative global period |
95 / 93 | Synchronous video or audio-only telehealth, per payer rules |
B1 / B2 | From 2027, Medicare visit-complexity adjustment (replaces G2211) |
Documentation checklist
Each problem addressed, with its status (stable, worsening, new)
Tests ordered or reviewed, and any external notes reviewed
Treatment decisions that show the risk level, such as prescriptions or OTC advice
Total time on the date of service, if coding by time, with activities listed
A diagnosis code for every problem addressed, linked to the visit
FAQ
What is CPT code 99213?
A level 3 established-patient office visit with low MDM or 20+ minutes of total time.
How many minutes is 99213?
At least 20 minutes of total practitioner time on the date of service. There is no longer an upper limit; at 30 minutes, report 99214.
How much does Medicare pay for 99213 in 2026?
$95.19 nationally in an office and $57.45 in a facility, before geographic adjustment.
Can 99213 be billed for telehealth?
Yes, for Medicare through December 31, 2027, and for most commercial payers under their own telehealth policies.
What's the difference between 99213 and 99214?
99213 is low MDM or 20 minutes; 99214 is moderate MDM or 30 minutes. Two stable chronic conditions, or one that is worsening, usually moves a visit to 99214.
Sources: CareRoute 99213 cost and RVU breakdown · Physicians Practice on the CY 2027 final rule · AMA MDM table (ACS reproduction) · ASCO MDM guide
