CPT Code 99213: Low Complexity E&M Visit

• CPT Codes
• 99213

CPT Code 99213: Low Complexity E&M Visit

CPT code 99213 for low complexity office visits. The most commonly billed E&M code. Billing guidance for behavioral health providers.

Quick Reference

Code

99213

Code System

CPT

Category

CPT Codes

Published

Mar 4, 2026

Reading Time

8 min

CPT® is a registered trademark of the American Medical Association. All CPT code descriptions on this page are paraphrased in original wording; consult the current CPT® codebook published by the AMA for authoritative descriptors.

Understanding CPT Code 99213: Low Complexity Office Visit

CPT code 99213 is the most commonly billed evaluation and management (E&M) code in the United States. It describes an office or other outpatient visit for an established patient requiring low complexity medical decision making or 20 to 29 minutes of total time. For behavioral health treatment centers, 99213 is the workhorse code for follow-up medication management visits, clinical reassessments, and routine check-ins where the provider makes active but straightforward clinical decisions.

This guide provides a detailed breakdown of when to use 99213, how to document it properly, and how to distinguish it from its neighboring codes — 99212 and 99214 — to ensure accurate coding and optimal reimbursement.

Definition and Purpose

CPT 99213 describes an office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low complexity medical decision making.

Code selection is based on either:

For 99213, the MDM level is low, defined by meeting at least two of the following three elements:

When using time, 99213 requires 20 to 29 minutes of total time on the date of the encounter.

• The level of medical decision making (MDM), or
• Total time spent on the date of the encounter

When to Use 99213 in Behavioral Health

CPT 99213 is the most frequently used E&M code in behavioral health medication management. It covers the typical follow-up visit where a prescriber checks in with a patient, reviews their response to treatment, and makes minor adjustments. Common scenarios include:

Routine medication management follow-ups. A psychiatrist or psychiatric nurse practitioner evaluates a patient who has been on a stable antidepressant for several months. The patient reports mild residual symptoms. The provider considers a minor dose adjustment and documents the rationale.

Follow-up for a single chronic condition. A patient with generalized anxiety disorder returns for a scheduled follow-up. The provider reviews symptoms, confirms the current medication is effective, and continues the treatment plan with no changes or minor modifications.

Post-stabilization check-ins. After an initial stabilization period in a residential or outpatient program, a provider performs a brief clinical reassessment to confirm the patient remains on track. The encounter involves reviewing one or two active problems and limited data.

Step-down planning. A provider evaluates a patient transitioning from a higher to a lower level of care. The clinical decisions are straightforward — confirming stability, adjusting visit frequency, and documenting the rationale for the level-of-care change.

When to code higher or lower

If the encounter involves only one self-limited problem with minimal data review and minimal risk, 99212 (straightforward MDM) may be more appropriate.

If the encounter involves multiple chronic conditions, prescription drug management with consideration of drug interactions, or moderate risk of complications, 99214 (moderate complexity MDM) is likely the correct code. See our detailed 99213 vs 99214 comparison on the 99214 page.

Documentation Requirements

MDM-based documentation

To support a 99213 claim based on MDM, the clinical note should demonstrate:

• Problems addressed — Document each problem evaluated during the encounter. For low complexity MDM, this typically means two or more self-limited or minor problems, or one stable chronic illness.
• Data reviewed or ordered — Document any data reviewed (lab results, prior records, imaging) or ordered during the encounter. For low MDM, limited data review is sufficient. Examples include reviewing a PHQ-9 score, checking a recent drug screen result, or ordering routine labs.
• Risk assessment — The risk level must be consistent with low risk. This includes encounters where the management plan involves over-the-counter medications, minor adjustments to existing prescriptions, or low-risk therapeutic interventions. If you are initiating or changing a prescription medication that requires monitoring, this may push the risk to moderate (supporting 99214 instead).
• Assessment and plan — A clear clinical assessment of the patient’s current status and a documented plan of care. The plan should reflect the decisions made during the encounter.
• History and/or examination — A medically appropriate history and/or examination. The extent is determined by the clinician based on the presenting problem. Under the current E&M guidelines, history and exam do not drive code level — MDM and time do.

Time-based documentation

When selecting 99213 based on time:

• Document total time: 20-29 minutes on the date of the encounter
• List activities performed: face-to-face evaluation, chart review, care coordination, documentation, counseling
• Time includes all activities performed on the date of the encounter, not just face-to-face time

Documentation tips for behavioral health

• Use validated screening tools (PHQ-9, GAD-7, AUDIT-C) and document the scores. This supports the “data reviewed” element of MDM.
• Document medication names, dosages, and any changes considered even if the decision is to continue the current regimen.
• Note the patient’s adherence to the treatment plan and any barriers to compliance.
• If combining E&M with add-on psychotherapy (90833, 90836, 90838), document the E&M and psychotherapy components separately.

Billing and Reimbursement

Medicare reimbursement

As of March 2026, the approximate Medicare national average reimbursement for CPT 99213 is around $97 in the non-facility (office) setting.

Geographic locality adjustments may increase or decrease these rates by 10-20% depending on the region.

Commercial and Medicaid reimbursement

Commercial insurance rates for 99213 typically range from $110 to $160, depending on the payer contract, geographic area, and provider specialty. Medicaid rates vary by state and are often comparable to or slightly below Medicare rates.

Billing with add-on psychotherapy codes

One of the most common billing patterns in behavioral health is combining an E&M code with an add-on psychotherapy code. When a provider performs both an E&M service (such as medication management) and psychotherapy during the same encounter:

• Bill the E&M code (e.g., 99213) as the primary service
• Bill the appropriate add-on psychotherapy code (90833 for 16-37 minutes, 90836 for 38-52 minutes, or 90838 for 53+ minutes)
• Document both services separately in the clinical note
• Do not use modifier 25 when billing add-on psychotherapy codes with E&M codes — the add-on codes are designed to be reported together with E&M services

Volume benchmarks

As the most commonly billed E&M code, 99213 typically represents approximately 30-40% of a behavioral health practice’s established patient E&M volume. Significant deviations from this benchmark (either high or low) may warrant a coding audit to ensure accuracy.

Common Modifiers

• Modifier 25 — Significant, separately identifiable E&M service on the same day as a procedure. Use when 99213 is billed alongside a separately reported procedure (not add-on psychotherapy codes).
• Modifier 95 — Synchronous telemedicine service. Use when the 99213 visit is conducted via real-time audio-video telehealth.
• Modifier 59 — Distinct procedural service. Rarely used with E&M codes but may apply in specific situations where services need to be distinguished.
• Modifier AI — Principal physician of record. Used in facility settings.

Compliance Considerations

Audit risk profile

Because 99213 is the most commonly billed E&M code, it receives regular audit scrutiny. Payers and the Office of Inspector General (OIG) look for:

• Bell curve anomalies: If a provider’s coding distribution is skewed heavily toward 99213 compared to peers in the same specialty, it may indicate routine coding at one level rather than coding to the service provided.
• Upcoding from 99212: Claims that do not demonstrate low complexity MDM — for example, encounters with only one minor problem and no data review — may be downgraded to 99212.
• Downcoding from 99214: Conversely, auditors may find that documented services actually support 99214, indicating the practice is leaving revenue on the table.
• Insufficient documentation: Notes that lack a clear assessment and plan, or that do not identify the specific problems addressed, will not support the claim.

Best practices

• Code to the encounter, not the clock. While time-based coding is a valid option, most 99213 encounters are more efficiently supported by MDM documentation.
• Avoid copy-forward without review. EHR copy-forward functionality can create notes that appear templated and do not reflect the specific encounter. Auditors flag identical notes across multiple visits.
• Train providers on the MDM table. Ensure prescribers understand the three MDM elements and can self-assess their encounters before assigning a code level.
• Review add-on psychotherapy billing. When 99213 is billed with psychotherapy add-on codes, both services must be documented separately and meet their respective requirements.
• Monitor payer-specific policies. Some Medicaid programs and commercial payers have unique requirements for E&M billing, including prior authorization or frequency limits.

Related Billing Codes

• 99205
• 99211
• 99212
• 99214
• 99215
• 99354

Reference tables

Common questions

Official sources

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