Code: 99213
Description: Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity.
Context: This code is commonly used for routine office visits with established patients. It’s appropriate when the visit involves addressing specific health issues with a relatively straightforward level of medical decision making.
Guidelines for Proper Use
- For Established Patients: Apply 99213 for office visits with patients who have been previously seen by the provider or practice. This code is not for new patient visits.
- Key Components Requirement: The visit should include at least two of the following three key components: an expanded problem focused history, an expanded problem focused examination, and/or medical decision making of low complexity.
- Documentation of Visit Elements: Ensure that healthcare providers’ documentation reflects the necessary components of the visit, including the nature of the problem(s) addressed and the complexity of medical decision making.
- Exclusion of More Complex Visits: Do not use 99213 for visits that involve more complex decision making or extensive examinations. Higher-level codes are available for such scenarios.
- Compliance with Evaluation and Management Guidelines: Use 99213 in accordance with standard evaluation and management guidelines, as well as payer-specific rules.
Common Misuses of 99213
- Using for New Patient Visits: Misuse occurs if 99213 is applied to the first-time visits of new patients. This code is intended for established patients.
- Overcoding for Simple Visits: Using 99213 for very brief or simple visits that do not meet the two out of three key components criteria is inappropriate.
- Undercoding More Complex Visits: Conversely, using 99213 for visits that involve more extensive examination or complex decision making is also a misuse, as such visits may warrant a higher-level code.