Office or other outpatient visit, established patient, level 3
Audit Defense & Denial Intelligence
Research-based denial patterns from OrbDoc Bill Analyzer
1. Insufficient documentation for level of service
Very CommonInsurance audits downgrade 99213 to 99212 when documentation doesn't support low complexity medical decision-making or documented time is under 20 minutes. This affects an estimated 15-25% of claims in post-payment audits.
Common Causes
- • Missing total time documentation (no start/end time or total minutes noted)
- • Insufficient detail in assessment and plan section
- • No clear statement of MDM elements (problems addressed, data reviewed, risk level)
Resolution Strategy
Provider adds time documentation or more detailed MDM elements, resubmit claim with corrected documentation. Most payers accept appeals with enhanced notes within 30-60 days.
2. Incorrect patient classification (new vs established)
CommonBilling 99213 for a patient who hasn't been seen by the practice in 3+ years triggers denial, as these should be coded as new patient visits (99202-99205). The '3-year rule' applies to any physician of the same specialty within the group practice.
Common Causes
- • Patient not seen in 36+ months but still in practice database
- • Previous visit was by different specialty within same group practice
- • Registration staff incorrectly marked patient as established
Resolution Strategy
If error confirmed, resubmit with correct new patient code (usually 99203 or 99204). If patient was actually established, provide documentation of visit within past 3 years.
3. Bundled with same-day procedure
CommonWhen 99213 is billed on the same day as a procedure with its own E/M component, payers deny the office visit as bundled unless Modifier 25 is appended to show significant, separately identifiable service.
Common Causes
- • Missing Modifier 25 when E/M was separate from procedure
- • E/M service was for same condition/problem as procedure
- • Documentation doesn't clearly distinguish E/M work from procedure decision
Resolution Strategy
Add Modifier 25 to 99213 and provide documentation showing E/M was significant and separately identifiable from procedure. Must demonstrate separate problem addressed or substantial additional work.
💬 Plain Language Explanation
What this means
This is a regular office visit with your doctor. Your doctor performed a standard examination, reviewed your health, and discussed your concerns.
Why you might see this
This is one of the most common codes on medical bills. It's used for routine check-ups, follow-up visits, or when you come in with a health concern that requires a standard level of medical evaluation.
Common context
Typically used for established patients (patients the doctor has seen before) with straightforward medical issues.
What to ask your provider
"'Was this a standard visit, or were additional services provided that might justify a higher-level code?'"
Relative Value Units (RVUs)
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Clinical Information
When to Use
Established patient visit with low complexity medical decision-making or 20-29 minutes total time
Common Scenarios
Documentation Requirements
- Chief complaint and history of present illness
- Expanded problem-focused exam (2-7 organ systems)
- Low complexity medical decision-making
- OR document 20-29 minutes total time with activities
Coding Guidelines
Common Modifiers
Bundling Rules
- Cannot bill with same-day preventive visit without modifier 25
- Subject to global surgical period restrictions
- Part of 10-day post-op global period for minor procedures
Exclusions
- Do not use for new patients (use 99202-99205)
- Do not use for time <20 minutes (use 99212)
- Do not use for time ≥30 minutes (use 99214)
Coding Notes
Clinical scenarios
- Chief complaint and history of present illness
- Expanded problem-focused exam (2-7 organ systems)
- Low complexity medical decision-making
- Chief complaint and history of present illness
- Expanded problem-focused exam (2-7 organ systems)
- Low complexity medical decision-making
- Chief complaint and history of present illness
- Expanded problem-focused exam (2-7 organ systems)
- Low complexity medical decision-making
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Code Details
Medicare Pricing
PFSRVU Breakdown
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Frequently Asked Questions
CPT 99213 is the billing code for "Office or other outpatient visit, established patient, level 3". Established patient visit with low complexity medical decision-making or 20-29 minutes total time
Medicare pays approximately $88.95 for CPT 99213 (national average). Actual payment varies by geographic location due to GPCI adjustments. Hospital and commercial insurance rates are typically 2-4x higher than Medicare rates.
CPT 99213 has a total RVU of 2.54, broken down as: Work RVU 1.30, Practice Expense RVU 1.14, and Malpractice RVU 0.10. RVUs (Relative Value Units) determine Medicare reimbursement rates.
The most common denial reason for CPT 99213 is "Insufficient documentation for level of service". Insurance audits downgrade 99213 to 99212 when documentation doesn't support low complexity medical decision-making or documented time is under 20 minutes. This affects an estimated 15-25% of claims in post-payment audits. Common causes include: Missing total time documentation (no start/end time or total minutes noted); Insufficient detail in assessment and plan section. Appeal success rate is approximately 70-80%.
Key documentation requirements for CPT 99213 include: Chief complaint and history of present illness; Expanded problem-focused exam (2-7 organ systems); Low complexity medical decision-making; OR document 20-29 minutes total time with activities. Missing or incomplete documentation is a leading cause of claim denials for this code.
Bundling considerations for CPT 99213: Cannot bill with same-day preventive visit without modifier 25. Subject to global surgical period restrictions Use an NCCI bundling checker to verify specific code combinations before billing.
Common modifiers for CPT 99213 include: 25 (Significant, separately identifiable E/M on same day as procedure), 95 (Synchronous telehealth (audio-video)), 93 (Audio-only telehealth when video capability offered but not used). Modifiers indicate special circumstances and can affect reimbursement or prevent claim denials.
The typical time requirement for CPT 99213 is 20-29 minutes total time on date of service. Time-based codes require documentation of the actual time spent providing the service.