CPT 99213 billing error statistic

CPT CODE - 99213 Established patient, moderate clinic visit.

Office or other outpatient visit for evaluation and management of an established patient.

For code 99213, the expanded assessment for office or other outpatient visit requires at least two out of these three key components to be present in the medical record:

o An expanded problem focused history

o An expanded problem focused examination

o Medical decision making of low complexity

A tip for code 99213 is to think of expanded visits as a sum of the continued symptoms or another extended form of the problem. Usually, the presenting problem or problems are of low to moderate severity. Typically 15 minutes are spent face-to-face with patient and/or family.

 A midlevel office visit is technically known as "office or other  outpatient visit for the evaluation and management of an established  patient." It is CPT code 99213.

The descriptors for the levels of E&M services recognize seven components, six of which are used in defining the levels of E&M services. These components are:

1. History (key component); four recognized types of history (problem-focused, expanded problemfocused, detailed, and comprehensive)
2. Examination (key component); four recognized types of examination (problem-focused, expanded problem-focused, detailed, and comprehensive)
3. Medical decision-making (key component); four recognized types of medical decision-making (straightforward, low complexity, moderate complexity, and high complexity)
4. Counseling (contributory factor)
5. Coordination of care (contributory factor)
6. Nature of presenting problem (contributory factor)
7. Time

When selecting the appropriate level of service for an Office Evaluation and Management (E/M) CPT code, the following requirements must be satisfied and adequately documented in the clinical record:

• New Patient (CPT 99201-99204) – requires all three key components
• Established Patient (CPT 99212-99214) – requires two of the three key components

CPT Code 99213 (All Specialties)

Established Patient Office or Other Outpatient Visit services are a focus area for the FY 2010 Medical Review Strategy. Analysis of claims in the May 2009 sample period reveals there were 217 CERT errors. Of this number, 135 (62.21%) were for BETOS categories primarily reporting Evaluation and Management (E/M) procedure codes. Approximately 82% of the CERT errors for E/M codes were for incorrectly coded services. BETOS Category M1B - Established Patient Office or Other Outpatient Visit services had the second highest number of errors in comparison to the other E/M BETOS categories. Review of claims in the November 2009 sample period for BETOS Category M1B-Established Office Visits for the time frame of 04/01/2008 through 03/31/2009, revealed that established office visits accounted for 40% of the E/M CERT errors. Incorrectly coded services made up approximately 68% of the errors in this BETOS Category. CPT code 99213 comprised 21% of the incorrectly coded errors.

To prevent future improper payments for these services, Medical Review is utilizing both a direct and a widespread educational approach to those Part B services identified in the CERT errors. Enrollment records reveal there are approximately 90,000 providers who are able to bill for E/M services. To better identify the common billing and coding errors, Prepayment Service Specific Reviews will be utilized. Information obtained through these reviews will be utilized to further enhance and develop additional educational program

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 physicians, other qualified health care professionals, 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. Typically, 15 minutes are spent face-to-face with the patient and/or family.  - average fee amount - $75 - $90

In Medical billing CPT code 99213 is the most used CPT code.  Here i have given the definition and rules for when submitting with other CPT codes such as injection, surgery and vaccination and other CPT codes.

Can medical procedure codes 99393 and 99213 be billed together 

Ans : Yes.

Note : A physical health (medical) provider, not a mental health provider. If you code your visit with a mental health or counseling visit you will be denied payment. You can bill medical E and M code (i.e. 99213, 99214, and 99215) using the length of the visit or the supporting elements of the visit. You must document either the length of time (and that greater than 50% of the time was spent in counseling or care coordination) or the key elements that make the diagnoses. This process also works for the way you would bill commercial health plans.

CPT codes: There are two options: (1) bill as a 99215 if you include all elements in the note. (2) bill both (a) 99393 for the health maintenance and (b) 99213 for the ADHD evaluation. A representative from Medicaid has told us they will pay in this instance. For commercial payors, you need to include the -25 modifier, but with Medicaid you do not.

ICD-9 codes: (1) V20.2 preventative care and (2) 314.0 for ADHD.

Can we use 59 modifier on CPT 81002 with 99213

Ans: We can not use.

 Solution: But we can use Mod 25 for CPT 99213.

Modifiers and Modifier Indicators for CPT 99213

The AMA CPT Manual defines modifiers that may be appended to HCPCS/CPT codes to provide additional information about the services rendered. Modifiers may be appended to HCPCS/CPT codes only if the clinical circumstances justify the use of the modifier. It is very important that our providers bill using the appropriate CPT/HCPCS and Modifiers. For example, when billing for separate identifiable services you must bill with the modifiers listed below in order to be eligible for reimbursement.

Modifier -25: Significant, separately identifiable Evaluation/Management by the Same Provider on the Same Date of Service of the Other Procedure or Service.

• May be appended to an evaluation and management (E&M) CPT code to indicate that the E&M service is significant and separately identifiable from other services reported on the same date of service.

• The E&M service may be related to the same or different diagnosis as the other procedure(s).

• Modifier -25 may be appended to E&M services reported with minor surgical procedures or procedures not covered by global surgery rules. Since minor surgical procedures and global procedures include preprocedure, intra-procedure, and post-procedure work inherent in the procedure, the provider should not report an E&M service for this work.


Patient is an 11-month old child who is brought into the pediatrician for a routine health check. At the time of the examination, the child is found to have an acute otitis media and is given a prescription for antibiotic medication.

Incomplete Billing Complete Billing

Diagnosis V20.2 (Routine infant or child health check) 382.9 (Otitis media, acute)

V20.2 (Routine infant or child health check) 382.9 (Otitis media, acute)

Code 99213 (Office or their outpatient visit for the E&M of an established patient) 99391 (Periodic comprehensive preventive medicine, age 1 or younger)


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