Summary & Overview
CPT 99213: Office Visit for Established Patients, Low Complexity
CPT code 99213 is a foundational billing code for office and outpatient visits involving established patients, representing low complexity evaluation and management services. This code is widely used across the United States, making it a critical element in both clinical practice and healthcare reimbursement. The code is applicable when a provider spends 20–29 minutes with a patient or when the visit involves a medically appropriate history and/or examination with low-level medical decision making.
Major national payers, including Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare, recognize and reimburse for CPT 99213. Its broad acceptance underscores its importance in primary care, internal medicine, and general practice settings. Readers will gain insight into the clinical context of this code, typical sites of service, and its role in routine patient management. The publication also covers relevant benchmarks, policy updates, and comparisons to related codes, providing a comprehensive overview for healthcare professionals, administrators, and policy analysts.
Understanding CPT 99213 is essential for accurate billing, compliance, and resource allocation in outpatient care. The code's widespread use and standardized criteria make it a key reference point for evaluating national trends in office visit utilization and reimbursement.
CPT Code Overview
CPT 99213 is used to report an office or other outpatient visit for the evaluation and management of an established patient. This code applies when the encounter requires a medically appropriate history and/or examination and a low level of medical decision making. When time is used for code selection, CPT 99213 corresponds to a total of 20–29 minutes spent on the date of the encounter. The typical site of service for this code is an office or other outpatient setting, such as Place of Service 11. This code is a core component of the Evaluation and Management—Office or Other Outpatient Services category, reflecting routine care for established patients with relatively straightforward clinical needs.
Clinical & Coding Specifications
Clinical Context
A patient with an established relationship to the practice presents for an office or outpatient visit. The encounter involves a medically appropriate history and/or examination, with a low level of medical decision making. Common scenarios include follow-up for chronic conditions such as essential hypertension, type 2 diabetes mellitus without complications, or evaluation of acute complaints like headache, low back pain, or upper respiratory infection. The provider spends 20–29 minutes on the date of the encounter, addressing the patient's concerns, reviewing relevant history, performing an examination as needed, and managing ongoing or new issues. The visit may occur in person or via telemedicine, depending on patient needs and practice capabilities.
Coding Specifications
-
Modifier
25: Used when a significant, separately identifiable evaluation and management service is performed by the same physician on the same day as another procedure or service. -
Modifier
95: Indicates a synchronous telemedicine service rendered via real-time interactive audio and video telecommunications system.
| Modifier Code | Description |
|---|---|
25 | Significant, Separately Identifiable E/M Service by the Same Physician on the Same Day |
95 | Synchronous Telemedicine Service Rendered via Real-Time Interactive Audio and Video Telecommunications System |
- Provider Taxonomies:
| Taxonomy Code | Specialty |
|---|---|
207Q00000X | Family Medicine Physician |
207R00000X | Internal Medicine Physician |
208D00000X | General Practice Physician |
Related Diagnoses
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J06.9: Acute upper respiratory infection, unspecified- Relevant for visits addressing symptoms such as cough, sore throat, or congestion, where the provider evaluates and manages an acute respiratory illness.
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E11.9: Type 2 diabetes mellitus without complications- Used for follow-up or management of diabetes in established patients, including medication review, lifestyle counseling, and monitoring.
-
I10: Essential (primary) hypertension- Applied when the visit involves evaluation and management of high blood pressure, including medication adjustment and monitoring.
-
M54.5: Low back pain- Relevant for encounters where the patient presents with back pain, requiring assessment, possible imaging, and management strategies.
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R51: Headache- Used for visits focused on evaluation and management of headache symptoms, including history, examination, and treatment planning.
Related CPT Codes
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99212: Established patient office or other outpatient visit, 10–19 minutes. Used for shorter, less complex visits with a lower level of medical decision making. Often selected when the encounter requires less time or complexity than99213. -
99214: Established patient office or other outpatient visit, 30–39 minutes. Used for longer, more complex visits with a moderate level of medical decision making. Selected when the encounter requires more time or complexity than99213.
| CPT Code | Description | Clinical Relationship |
|---|---|---|
99212 | Established patient office or other outpatient visit, 10–19 minutes | Alternative for less complex or shorter visits |
99213 | Established patient office or other outpatient visit, 20–29 minutes | Primary code for low complexity, moderate time visits |
99214 | Established patient office or other outpatient visit, 30–39 minutes | Alternative for more complex or longer visits |
99212 and 99214 are commonly used as alternatives to 99213 depending on the complexity and time spent during the encounter. These codes are not typically billed together for the same patient on the same date, but selection depends on the clinical scenario and documentation.
National Reimbursement Benchmarks
Medicare's national mean rate for CPT code 99213 is $98.28, which is higher than the BUCA (Blue Cross Blue Shield, UnitedHealth Group, Cigna, and Aetna) average commercial mean rate of $86.34. Among individual commercial payers, Cigna and UnitedHealth Group have mean rates above Medicare, while Aetna and Blue Cross Blue Shield are below.
Rate dispersion, measured by the difference between the 75th and 25th percentiles, varies across payers. Medicare shows the tightest range at $8.00, indicating less variability in reimbursement. Cigna and UnitedHealth Group have the widest ranges, at $53.28 and $54.00 respectively, reflecting greater variability in commercial rates. Aetna, Blue Cross Blue Shield, and BUCA have moderate dispersion.
The table and chart below present the full breakdown of national benchmarks for CPT code 99213 by payer.
State Benchmarks
State: AK1 / 50
Alaska Benchmarks
Alaska exhibits a wide spread in reimbursement rates for CPT code 99213, with the 75th percentile minus the 25th percentile ranging from $21.57 for Aetna up to $83.75 for Cigna. This indicates substantial variability in payment levels across payers, especially among commercial insurers. Compared to national averages, Alaska's mean rates for all major payers are markedly higher, with UnitedHealth Group and Blue Cross Blue Shield showing the most pronounced differences.
The table and chart below present the full breakdown of payer-specific rates, including mean, 25th, 50th, and 75th percentiles, highlighting the significant premium Alaska providers receive relative to national benchmarks.
Key Insights for Alaska
- UnitedHealth Group is the highest paying payer for CPT 99213 in Alaska, with a mean rate of $170.81.
- Medicare is the lowest paying payer in Alaska, with a mean rate of $95.75.
- All commercial payers in Alaska reimburse at rates significantly above their respective national averages, with UnitedHealth Group and Blue Cross Blue Shield showing the largest deviations.
Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.