CPT 99213: Established Patient Office Visit — Requirements & Documentation

CPT 99213 — Office/outpatient visit, established patient, low-level MDM OR 20–29 minutes total time (2021+ guidelines).

2021+ Code Selection (Time OR MDM)

Component	99213 Threshold
Total Time	20–29 minutes (clinician face-to-face + non-face-to-face same day)
MDM Level	Low — 2 of 3: • Problems: 2+ self-limited, or 1 stable chronic, or 1 acute uncomplicated • Data: Minimal (review 1–2 external notes, order 1–2 tests) • Risk: Low (OTC meds, minor procedure no risk factors)

Pre-2021 (Historical — 3 of 3 Components)

• History: Expanded problem-focused (HPI 1–3 elements + ROS 1 system + PFSH none).
• Exam: Expanded problem-focused (2–7 systems/bullets).
• MDM: Low complexity.
• Typical time: 15 minutes.

Typical Clinical Scenarios

• Follow-up for 1–2 stable chronic conditions (HTN, DM, hypothyroidism).
• Acute uncomplicated issue (URI, UTI, dermatitis) in established patient.
• Medication management with minimal adjustment.
• Review of labs/imaging with straightforward plan.

Documentation Essentials

• Chief concern + HPI (context, severity, timeline).
• Relevant ROS & PFSH (pertinent positives/negatives).
• Focused exam (affected systems).
• Assessment/Plan: Diagnosis, rationale, orders, follow-up, patient education.
• Time statement if billing by time: "Total time 25 minutes: 15 min face-to-face, 10 min coordination/chart review."

Common Pitfalls

• Upcoding to 99214 without moderate MDM or 30+ min.
• Downcoding 99212 when low MDM met but time not documented.
• Missing MDM documentation — "patient doing well, continue meds" = insufficient.