CPT 99213
Global XXX ActiveOffice o/p est low 20 min
CPT 99213 Billing & Documentation Guide
CPT code 99213 (Office o/p est low 20 min) is classified under E/M with a global period indicator of XXX. The 2026 Medicare Physician Fee Schedule assigns a work RVU of 1.3, a non-facility practice expense RVU of 1.46, and a malpractice RVU of 0.09, a total non-facility RVU of 2.85 and facility RVU of 1.72. With the current conversion factor of $33.4009, the national average non-facility reimbursement is approximately $97.78, though rates vary from $86.86 to $120.13 based on MAC locality and Geographic Practice Cost Indices (GPCIs).
When billing 99213, ensure documentation supports medical necessity and the specific components required for the code's level of service. For E/M codes, document MDM (medical decision-making) elements: problems addressed, data reviewed, and risk. For procedural codes, document the indication, technique, and any complications. Always verify NCCI edits before bundling 99213 with related codes; this code has 10 PTP bundling relationships on file (see table below).
Coding Tips for 99213
Real-world specialist guidance from the PayerReady Medical Coding Team, not generic boilerplate.
E/M 99213 is the most-billed established patient visit code (73.6M Medicare claims/year). Studies show 30-40% of charts coded as 99213 actually support 99214 documentation. The revenue gap is about $48 per visit; for a practice with 2,000 such visits per year, that is $96K of left-on-the-table revenue.
Time threshold (2021 rules): 20-29 minutes total time on date of encounter. Document specific time, e.g., "Total time spent today: 24 minutes including chart review and documentation."
MDM threshold: Low complexity. Two of three required: low number of problems (one stable chronic OR one acute uncomplicated), limited data (review one external test OR one independent historian OR review of prior notes), low risk (OTC drug management or minor outpatient procedure).
Modifier 25 reminder: When billing this E/M with a same-day procedure (injection, EKG, vaccine administration), append modifier 25 to the E/M and document a separately identifiable problem beyond the routine pre-procedure evaluation. OIG audits show 42% of modifier 25 claims fail documentation review.
Payment Status & Global Period
Active code (paid under MPFS)
No global period (E/M and other non-procedural services)
MUE Limit (Medically Unlikely Edits)
Submitting more than 2 units of 99213 for the same patient on the same date triggers automatic line denial unless an appropriate modifier and supporting documentation justify the higher quantity.
RVU Breakdown, CPT 99213
| Component | Non-Facility | Facility |
|---|---|---|
| Work RVU | 1.3 | 1.3 |
| Practice Expense RVU | 1.46 | 0.33 |
| Malpractice RVU | 0.09 | 0.09 |
| Total RVU | 2.85 | 1.72 |
| Conversion Factor | $33.4009 | |
2026 Medicare Reimbursement by State, CPT 99213
State-level averages across all MAC localities. Non-facility rates typically apply to office-based services; facility rates apply to hospital outpatient / inpatient.
| State | Non-Facility | Facility | Range (Non-Fac) | Localities |
|---|---|---|---|---|
| California | $104.31 | $59.65 | $99.22 - $120.13 | 29 |
| Florida | $98.2 | $60.33 | $94.56 - $101.79 | 3 |
| Georgia | $93.6 | $57.6 | $90.5 - $96.71 | 2 |
| Illinois | $96.44 | $59.97 | $92.64 - $99.63 | 4 |
| Michigan | $93.45 | $58.01 | $91.34 - $95.55 | 2 |
| North Carolina | $90.84 | $55.63 | $90.84 - $90.84 | 1 |
| New York | $103.97 | $61.86 | $91.86 - $109.76 | 5 |
| Ohio | $90.97 | $56.51 | $90.97 - $90.97 | 1 |
| Pennsylvania | $94.79 | $57.82 | $91.03 - $98.55 | 2 |
| Texas | $94.46 | $57.3 | $90.59 - $97.77 | 8 |
Source: CMS PFSRVU 2026 · Updated 2026-04-01. Full locality-level detail available for all 53 states, contact us for custom reports.
NCCI Bundling Edits, CPT 99213
Procedure-to-procedure (PTP) edits. If you bill any of these codes with 99213 on the same date of service, review the modifier indicator and payer policy before submission.
| Partner Code | Relationship | Modifier Allowed | Rationale |
|---|---|---|---|
| 0074T | Column 1 (primary), can be billed with modifier | 9 | CPT Manual or CMS manual coding instruction |
| 0115T | Column 1 (primary), can be billed with modifier | Yes | Misuse of Column Two code with Column One code |
| 0116T | Column 1 (primary), can be billed with modifier | Yes | Misuse of Column Two code with Column One code |
| 0359T | Column 1 (primary), can be billed with modifier | Yes | Misuse of Column Two code with Column One code |
| 0360T | Column 1 (primary), can be billed with modifier | Yes | Misuse of Column Two code with Column One code |
| 0361T | Column 1 (primary), can be billed with modifier | Yes | Misuse of Column Two code with Column One code |
| 0362T | Column 1 (primary), can be billed with modifier | Yes | Misuse of Column Two code with Column One code |
| 0362T | Column 1 (primary), can be billed with modifier | Yes | Misuse of Column Two code with Column One code |
| 0363T | Column 1 (primary), can be billed with modifier | Yes | Misuse of Column Two code with Column One code |
| 0364T | Column 1 (primary), can be billed with modifier | Yes | Misuse of Column Two code with Column One code |
Frequently Asked Questions, CPT 99213
What does CPT code 99213 mean? +
CPT code 99213 represents: Office o/p est low 20 min. It's in the E/M category with a global period of XXX.
What is the Medicare reimbursement for CPT 99213? +
The 2026 Medicare national average non-facility payment for CPT 99213 is $97.78. Rates range from $86.86 to $120.13 across 53 states depending on MAC locality and GPCIs.
What modifiers can I use with CPT 99213? +
E/M codes commonly use modifier 25 (significant separately identifiable E/M on same day as a procedure), 57 (decision for major surgery), 24 (unrelated E/M during global period), 95 (synchronous audio+video telehealth), 93 (audio-only telehealth), and AI (principal physician of record on admission). Surgical modifiers like 50, 51, 59 do not apply to E/M.
What bundling edits apply to CPT 99213? +
This code has 10 NCCI PTP bundling relationships. See the NCCI Bundling section below for full list.
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Reviewed by the PayerReady Medical Coding Team
Verified against the CMS 2026 code set on May 31, 2026.
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