(2022) CPT Code 99213 – Description & Clinical Examples

This article will define CPT Code 99213, explain the medical necessity to report CPT 99213, the guidelines and clinical examples of CPT 99213.

CPT Code 99213 Description

CPT Code 99213 is defined by the CPT manual as follows (the text in Italic is the official definition of CPT 99213):

Office visit or other outpatient consultation to evaluate and treat an established patient who requires a medically appropriate medical history and / or examination and a low level of medical decision-making.

If time is used for code selection, 20 – 29 minutes of total time will be spent on the date of the match.

An established patient is one who, in the last three years, has made use of professional services by a doctor or another doctor in the same field and specialization belonging to the same practice group.

In the event that a qualified physician / healthcare professional is on call for another qualified physician / healthcare professional or replaces another qualified physician / healthcare professional, the patient’s encounter will be classified as unavailable to a physician / qualified healthcare professional.

CPT code 99213 can be used for a mid-level outpatient or hospital visit. The CPT code 99213 is a level 3 code that must be used for a registered patient. It can not be utilised in a new patient with no medical history.

However, this code is very commonly used because it is the second most popular among the mid-level billing CPT codes. This is mostly because reimbursement factors are more easily accessible with this CPT code than with other CPT codes, including 99214.

CPT code 99214 can be utilised as part of the second highest level of care for a patient visit. The CPT code 99214 is a level CPT code that can only be used for a registered patient, regardless of whether the visit is in practice or in an outpatient setting.

So, it is not surprising that the CPT code 99214 is the most used for this type of visit. It offers higher revenue / rebates than some similar CPT codes, with addition to CPT code 99213. This has been particularly true since changes in 2013, along with the inclusion of mental health care in the Affordable Care Act of 2006.

CPT 99213 RVUs

The following points show the total RVUs for the first quarter of 2021 and the fourth quarter of 2020 for CPT code 99213.

The RVUs of MPFS facilities are often less than the RVUs of the non-facility (office) as the physician is responsible less practical costs when a physician provides services in a facility. Final reimbursement amounts for E / M services don’t just depend on these RVUs.

• 2020 Q4 RVUs – 2.11 (Non-Facility) – 1.45 (Facility)
• 2021 Q1 RVUs – 2.68 (Non-Facility) – 1.95 (Facility)

CPT Code 99213 Examples

Example 1

Office visit for an established patient with new lesions of lichen planus in spite of topical therapies. (Dermatology)

Example 2

Office visit for the quarterly follow-up of a 45-year-old lame with stable chronic asthma requiring regular drug therapy. (Allergy & Immunology)

Example 3

Office visit for a 13-year-old, established patient, with comedopapular acne of the face that has shown poor response to topical medication, Discussion of use of systemic medication. (Dermatology)

Example 4

Office visit for a 62-year-old female, established patient, for follow-up for stable cirrhosis of the liver. (internal Medicine/Family Medicine)

Example 5

Office visit for a 3-year-old, established patient, with atopic dermatitis and food hypersensitivity for quarterly follow-up evaluation ,The patient is on topical lotions and steroid creams as well as oral antihistamines. (Allergy & Immunology)

Example 6

Office visit for an 80-year-old female, established patient, to evaluate medical management of osteoarthritis of the temporomandibular joint. (Rheumatology)

Example 7

Office visit for a 70-year-old female, established patient, one year post excision of basal cell carcinoma of nose with nasolabial flap, Now presents with new suspicious recurrent lesion and suspicious lesion of the back. (Plastic Surgery)

Example 8

Office visit for a 68-year-old female, established patient, with polymyalgia rheumatic, maintained on chronic low-does corticosteroid, with no new complaints.(Rheumatology)

Example 9

Office visit for a 3-year-old female, established patient, for earache and dyshidrosis of feet. (Pediatrics/Family Medicine)

Example 10

Office visit for an established patient for 18-months post-operative follow-up of TMG repair. (Oral & Maxillofacial Surgery)

Example 11

Office visit for a 45-year-old male, established patient, being re-evaluated for  recurrent acute prostatitis. (Urology)

Example 12

Office visit for a 43-year-old male, established patient, with known reflex sympathetic dystrophy. (Anesthesiology)

Example 13

Office visit for an established patient with an evenly pigmented superficial nodule of leg that is symptomatic. (Dermatology)

Example 14

Office visit for an established patient with psoriasis involvement of the elbows, pitting of the nails, and itchy scalp. (Dermatology)

Example 15

Office visit for a 27-year-old male, established patient, with deep follicular and perifollicular inflammation unable to tolerate systemic antibiotics due to GI upset, requires change of systemic medication. (Dermatology)

Example 16

Office visit for a 16-year-old male, established patient, who is on medication for exercise-induced bronchospasm. (Allergy & Immunology)

Example 17

Office visit for a 60-year-old, established patient, with chronic essential hypertension on multiple drug regimen, for blood pressure check. (Family Medicine)

Example 18

Office visit for a 20-year-old male, established patient, for removal of sutures in hand. (Family Medicine)

Example 19

Office visit for a 58-year-old female, established patient, with unilateral painful bunion. (Orthopaedic Surgery)

Example 20

Office visit for a 45-year-old female, established patient, with known osteoarthritis and painful swollen knees. (Rheumatology)

Example 21

Office visit for a 25-year-old female, established patient, complaining of bleeding and heavy menses. (Obstetrics & Gynecology)

Example 22

Office visit for a 55-year-old male, established patient, with hypertension managed by a beta blocker/thiazide regime;  now experiencing mild fatigue. (Nephrology)

Example 23

Office visit for a 65-year-old female, established patient, with primary glaucoma for interval determination of intraocular pressure and possible adjustment of medication. (Ophthalmology)

Example 24

Office visit for a 56-year-old man, established patient, with stable exertional angina who complains of new onset of calf pain while walking. (Cardiology)

Example 25

Office visit for a 63-year-old female, established patient, with rheumatoid arthritis on auranofin and ibuprofen, seen for routine follow-up visit. (Rheumatology)

Example 26

Office visit for an established patient with Graves’s disease, three months post I-131 therapy, who presents with lassitude and malaise.(Endocrinology)

Example 27

Office visit for the quarterly follow-up of a 63-year-old male, established patient, with chronic myofascial pain syndrome, effectively managed by doxepin, who presents with new onset urinary hesitancy. (Pain Medicine)

Example 28

Office visit for the biannual follow-up of an established patient with migraine variant having infrequent, intermittent, moderate to severe headache with nausea and vomiting, which are sometimes effectively managed by ergotamine tartrate and an antiemetic, but occasionally requiring visits to an emergency department. (Pain Medicine)

Example 29

Office visit for an established patient after discharge from a pain rehabilitation program to review and adjust medication dosage. (Pain Medicine)

Example 30

Office visit with 55-year-old male, established patient, for management of hypertention, mild fatigue, on beta blocker/thiazide regimen. (Family Medicine/Internal Medicine)

Example 31

Outpatient visit with 37-year-old male, established patient, who is three years post total colectomy for chronic ulcerative colitis, presents for increased irritation at his stoma. (General Surgery)

Example 32

Office visit for a 70-year-old diabetic hypertensive established patient with recent change in insulin requirement. (Internal Medicine/Nephrology)

Example 33

Office visit with 80-year-old female, established patient, for follow-up osteoporosis, status-post compression fractures. (Rheumatology)

Example 34

Office visit for an established patient with stable cirrhosis of the liver. (Gastroenterology)

Example 35

Routine, follow-up office evaluation at a three-month interval for a 77-year-old female, established patient, with nodular small cleaved-cell lymphoma. (Hematology/Oncology)

Example 36

Quarterly follow-up office visit for a 45-year-old male, established patient, with stable chronic asthma, on steroid and bronchodilator therapy. (Pulmonary Medicine)

Example 37

Office visit for a 50-year-old female, established patient, with insulin-dependent diabetes mellitus and stable coronary artery disease, for monitoring. (Family Medicine/Internal Medicine)