Office o/p est low 20 min
CPT code 99213 is used for a routine office visit with an established patient that involves low-level medical decision making and typically takes about 20 minutes. This is one of the most common billing codes for follow-up appointments and routine check-ins.
This calculator gives a typical-case estimate using standard Medicare modifier rules. Actual payment depends on payer policies, documentation, code-specific CMS status indicators, and locality. Verify before billing.
RVU breakdown
Conversion factor: 32.3465 · Source: CMS MPFS RVU25A · Confidence: High
NCCI bundling edits
Loading bundling edits…
Billing tips
Time-based billing: Document total time on date of encounter when time exceeds 20 minutes, even if MDM is low level
Impact: 20-29 minutes qualifies for 99213 ($88.95), but 30-39 minutes qualifies for 99214 ($130.07), increasing payment by $41.12
Medical decision making: Ensure documentation captures at least 2 of 3 MDM elements (problems addressed, data reviewed, risk) at low level
Impact: Inadequate MDM documentation may result in downcoding to 99212 ($63.68), reducing payment by $25.27 per encounter
Incident-to billing: When NPPs see established patients, ensure physician is on-site and service is continuation of physician's plan
Impact: Incident-to billing yields 100% of physician fee schedule ($88.95) vs 85% when billing under NPP's NPI ($75.61), a $13.34 difference
Prolonged service add-on: When total time reaches 40 minutes, append CPT 99417 for each additional 15 minutes
Impact: Adding 99417 for 40+ minute visits increases reimbursement by approximately $46.20 per 15-minute increment
Separate problem documentation: When billing 99213 with modifier 25, clearly document the E&M service addresses a problem separate from the procedure
Impact: Clear separation prevents modifier 25 denials which would eliminate the entire $88.95 E&M payment
Chronic care management coordination: Document care coordination time separately; if 20+ minutes monthly, bill CCM codes in addition to 99213
Impact: CCM code 99490 adds $44.06 monthly per qualified patient on top of regular visit reimbursement
Top denial reasons
- Modifier missing or wrong33% (3)
- Bundled into another code (NCCI edit)22% (2)
- Documentation issue22% (2)
- Prior authorization required11% (1)
- Frequency limit exceeded11% (1)
Most reported payers
- UnitedHealthcare22% (2)
- Anthem22% (2)
- Cigna11% (1)
- Aetna11% (1)
- Other11% (1)
Appeal intelligence
Get the free Revenue Protection Toolkit — the denial triggers, modifier pitfalls, and bundling conflicts that quietly cost you reimbursement. Instant download.
Help build the field knowledge
MedPayIQ gets smarter as billers contribute. If you've had this code denied, share what happened so others learn from it. Anonymous, no patient info.