CPT code 99213 is an important code for mental health practitioners to understand. This code is used for outpatient office or other outpatient visits for the evaluation and management of an established patient.
Key Takeaways
- CPT code 99213 is for established patients with presenting problems of moderate severity. The typical visit is 15 minutes.
- Reimbursement rates for 99213 vary by payer but average $93 nationally. Rates are adjusted annually.
- To bill 99213, the visit must meet the three key components – history, exam, and medical decision-making.
- 99213 is an intermediate-level visit between low complexity 99212 and high complexity 99214/99215.
What is CPT Code 99213?
CPT stands for Current Procedural Terminology. CPT codes are used by healthcare providers to bill insurance companies and Medicare/Medicaid for services rendered.
Specifically, 99213 is the CPT billing code for outpatient or other outpatient visits for the evaluation and management of an established patient.
An established patient is someone the provider has seen previously. A new patient would be coded as 99201-99205.
CPT Code 99213 Details
- 99213 is for the treatment of problems of moderate severity. This is in contrast to low severity 99212 or high severity 99214/99215.
- The typical visit length for 99213 is 15 minutes face-to-face with the provider. Visits 10-19 minutes can be billed as 99213.
- For 99213, the presenting problems require a detailed history, detailed exam, and medical decision-making of moderate complexity. More on this later.
- The place of service for 99213 is the outpatient setting. This includes a private office, mental health clinic, etc. Not for the inpatient or emergency room.
- Diagnostic and therapeutic procedures like psychotherapy may be provided in addition to 99213 but don’t drive the code selection.
What is Reimbursement for 99213?
Reimbursement rates for CPT code 99213 vary by geographic location and payer. On average, the national reimbursement rate for 99213 is around $93.
However, Medicare may pay $87 in one state and $104 in another. Commercial insurers also have varying contractual rates based on plan type and location. Medicaid rates can be lower as well.
It’s important for practices to verify benefits and determine fee schedules with each payer to quote accurate rates for 99213.
Rates are adjusted periodically too – usually on an annual basis. So the 99213 reimbursement for 2022 is not the same as it will be in 2024. Stay up to date!
Sample 99213 Reimbursement Rates
- Medicare: $87-$104
- Medicaid: $68-$78
- Blue Cross Blue Shield: $88-$112
- Aetna: $90-$110
- Cigna: $91-$107
- UnitedHealthcare: $86-$102
Billing Requirements for 99213
To report 99213, the visit must include the following 3 key components:
i- Comprehensive History
- Chief complaint (reason for the visit)
- History of present illness
- Review of systems
- Past psychiatric/medical/family history
ii- Comprehensive Exam
- General appearances
- Behavior
- Mood and affect
- Cognitive exam
- Thought process/content
- Insight and judgments
iii- Medical Decision Making
- Moderate complexity decision-making (multiple diagnoses/data reviewed)
- Moderate risk of complications from the presenting problems
- Prescribing medications and ordering tests/procedures
- Discussion of management options and providing counseling
All 3 key components must be met to report 99213. Failing to document this could lead to claim denials or down-coding to a lower level.
Distinguishing 99213 from Other E/M Codes
It’s helpful to understand how 99213 differs from 99212 and 99214/99215:
99212
- For problems of low severity
- The typical time is 10 minutes
- Only requires problem-focused history, exam, and decision making
99213
- For problems of moderate severity
- The Typical time is 15 minutes
- Requires detailed history, exam, and moderate complexity decision-making
99214
- For problems of moderate-high severity
- The Typical time is 25 minutes
- Detailed history, exam, and high-complexity decision-making
99215
- For problems of high severity
- The typical time is 40 minutes
- Comprehensive history, exam, and high-complexity decision-making
So in summary, as complexity increases from 99212 to 99215, so does the typical time, extent of history/exam, and complexity of medical decision-making.
99213 sits right in the middle between low and high-complexity visits.
Examples of Appropriate Use of 99213
Here are some examples of patient visits that may meet the criteria for 99213:
- 15-minute medication management appointment for depression where dosage was adjusted after a review of symptoms and side effects. Moderate MDM to change medication regimen.
- Initial psychotherapy intake lasts 17 minutes for a patient with relationship problems. Detailed history, mental status exam, and counseling were provided.
- A 12-minute follow-up visit for management of anxiety. Detailed exam and discussion of diagnostic results and medication options.
- Weekly 25-minute therapy sessions focused mainly on counseling for an established patient with moderate depression. Even though the time was 25 minutes, MDM was low complexity so 99213 is the most accurate.
The key is choosing the code based on the 3 components, not just time. Time can help guide the choice but doesn’t drive code selection alone.
Tips for Documenting 99213
Here are some tips for documenting appropriately to support billing 99213:
- Clearly state the chief complaint and history of the present illness
- Document a detailed review of systems and psychiatric exam
- Note diagnosis, management options reviewed, and moderate complexity decision-making
- Specify time spent face-to-face counseling and coordinating care
- Include any labs ordered, procedures done, or medications prescribed
- Use time as a guide but have your note focus on complexity over visit length
Thorough chart documentation is key to receiving proper payment for services billed. Failing to document correctly could lead to a claim denial or reimbursement lower than 99213.
What About Therapy and 99213?
Psychotherapy can be provided in addition to 99213 but doesn’t drive code selection alone.
Time spent providing psychotherapy like cognitive behavioral therapy is not included in the typical times for the E/M codes.
For example, you could see a patient for 50 minutes, and provide 45 minutes of psychotherapy, but bill 99213 because the face-to-face E/M services were low complexity.
Conversely, you could have a 15-minute medication management visit at higher complexity meeting criteria for 99214 – even though the total time was short.
Changes Coming to E/M Coding in 2021
The CPT coding guidelines for office visits are being updated in 2021 to allow providers to choose a code based on either total time or medical decision-making.
There will no longer be a history/exam component required. This will further simplify the coding process.
The typical times will likely be adjusted too. Until the changes roll out, continue using the current framework focused on history, exam, and complexity over time.
Factors Affecting 99213 Reimbursement
In addition to the payer, some other factors impacting 99213 reimbursements include:
- Location – Rates differ based on metropolitan or rural areas due to cost-of-living adjustments
- Visit complexity – More time/medical decision-making increases rate up to 99214 level of care
- Provider specialty – Rates may be higher for specialties like behavioral health
- Care management – Additional reimbursement possible for care coordination activities
- Billing accurately – Appending modifiers like 25 for significant/separately identifiable E&M service
Frequently Asked Questions – FAQs
Yes, 99213 is appropriate for a telemedicine visit with an established patient that meets the key components.
Group therapy uses different CPT codes in the 90853 series. 99213 is for individual outpatient visits only.
Yes, 99213 can be used for medication management visits with established patients if the complexity criteria are met. Time alone does not qualify.
No, virtual check-ins, e-visits, and phone calls are reported separately from in-person 99213 office outpatient visits.
Yes, you can bill 99213 with therapy add-on codes like 90833 or 90836 if counseling is also provided at the visit.
Conclusion
Understanding the ins and outs of 99213 coding, documentation, and reimbursement is key for accurate claim submission and optimal payment.
As a mental health provider, focus on choosing the CPT code based on complexity over time spent. And make sure your patient notes adequately support the level billed.
This ensures you receive full reimbursement for the important mental healthcare services you provide. Consider this your definitive guide to navigating 99213!
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