Is 99213 covered under CMS LCD or NCD policies?

Applicable CMS coverage references for 99213: LCD L34567 (Outpatient E/M Services).

CPT System Family Medicine Active Code (2026)

99213

Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 15 minutes face-to-face with the patient and/or family.

Q: What is the official clinical definition of CPT code 99213?

The official clinical description for 99213 is: Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 15 minutes face-to-face with the patient and/or family..

Q: What are the billing guidelines and documentation requirements for 99213?

To properly bill 99213, medical providers must ensure clear documentation of medical necessity. Requires medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter. Must document chief complaint, history of present illness, review of systems, physical exam, and assessment/plan detailing low complexity MDM.

Q: What modifiers are applicable when billing 99213?

Commonly accepted modifiers for 99213 include: 25 (Significant, separately identifiable E/M by same physician on same day of procedure), GC (Service performed in part by resident).

Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 15 minutes face-to-face with the patient and/or family.

RCM Financial Impact

1.3 Facility RVU

Pre-scrubbed & verified by Codes-For-MD AI claim engine for NCCI compliance.

Official Clinical Definition

Code System

CPT

Clinical Category

Procedures

Effective Date

2020-01-01

Billing Guidelines & Coding Notes

Requires medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter.

Official Coding Guidelines

Select E/M level based on Medical Decision Making (MDM) or Total Time. Do not count time spent on separately billable procedures.

Documentation Checklist for Medical Necessity

To prevent RAC audits and ensure first-pass claim reimbursement, medical chart notes for 99213 must explicitly verify the following components:

Must document chief complaint, history of present illness, review of systems, physical exam, and assessment/plan detailing low complexity MDM.

Allowed Modifiers

25 (Significant, separately identifiable E/M by same physician on same day of procedure), GC (Service performed in part by resident)

CMS LCD / NCD Coverage

LCD L34567 (Outpatient E/M Services)

Educational Guide: Optimizing 99213 in RCM

Proper utilization of 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 15 minutes face-to-face with the patient and/or family.) is critical for maintaining a healthy practice revenue cycle. Under-coding this service leads to significant revenue leakage, while over-coding or failing to meet NCCI edit standards triggers immediate payer denials and potential compliance audits.

When integrating 99213 into your superbills or EHR templates, ensure that your clinical staff correlates the diagnosis codes (ICD-10) to support the precise medical necessity of the procedure. Utilizing an automated claim scrubbing solution like Codes-For-MD's AI RCM platform guarantees that modifier combinations are validated prior to clearinghouse transmission.

Frequently Asked Questions about 99213

The official clinical description for 99213 is: Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 15 minutes face-to-face with the patient and/or family.. This code is used by healthcare providers to classify the specific service, procedure, or diagnosis for medical billing.

To properly bill 99213, medical providers must ensure clear documentation of medical necessity. Requires medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter. Must document chief complaint, history of present illness, review of systems, physical exam, and assessment/plan detailing low complexity MDM.

Commonly accepted modifiers for 99213 include: 25 (Significant, separately identifiable E/M by same physician on same day of procedure), GC (Service performed in part by resident). Modifiers are used to indicate that a service or procedure was altered by some specific circumstance but not changed in its definition or code.

Codes-For-MD AI utilizes advanced NLP and machine learning to pre-scrub claims containing 99213, verifying correct modifier usage, NCCI edit compliance, and LCD/NCD medical necessity rules before submission to prevent claim denials.