CPT code 99213: Office visit, established patient, low complexity2026 Medicare rate & RVUs

Medicare pays $95.19 for 99213 nationally in the office and $57.45 in a hospital or facility. Local office rates run $86.86–$120.13.

Medicare allowed amount for participating (non-QP) physicians, before deductible, coinsurance and claim adjustments. Not a patient’s bill or a hospital charge.

What 99213 covers

This visit covers an established patient seen in an office, clinic, or other outpatient setting. Examples include follow-up for one stable chronic condition, such as controlled hypertension, or assessment of an uncomplicated urinary tract infection or sinusitis. Physicians, nurse practitioners, and physician assistants report it across primary care and specialty practices. The encounter may include a medically appropriate history and examination, but those activities do not set the visit level.

Select the level by medical decision making or total billing practitioner time on the encounter date. Low decision making requires two of three elements at the low level: problems addressed, data reviewed or analyzed, and management risk. Limited data may be met by an independent historian or the required combination of distinct record reviews, test reviews, and test orders; an over-the-counter treatment recommendation may indicate low risk. Alternatively, at least 20 minutes supports 99213, including qualifying review, documentation, and care coordination, but excluding clinical staff time. Document the problems and decision-making elements, or the practitioner's total time. A patient is established after professional services from the practitioner or a same-specialty, same-subspecialty group member within three years. Medicare assigns lower practice expense RVUs in a facility than in an office.

This summary was written with AI assistance from CMS physician fee schedule data and checked against the CMS billing rules shown here. Rates on this page come directly from CMS files.

Where 99213 pays more and less

The same RVUs, adjusted for each area’s costs. Open a locality for its calculation, history and nearby areas.

109 of 109 payment localities

99213 rates by state

Office rate range in each state. Select a state to see its payment localities.

How the 99213 rate is calculated

Each of 99213’s three RVUs is multiplied by a geographic index (GPCI) for the payment locality, added up, and multiplied by the conversion factor. Drag the indexes or enter a ZIP to see what moves the rate.

Payment rules and modifiers for 99213

99213 has no global surgery period, no multiple-procedure, bilateral or assistant-at-surgery adjustment, and no professional/technical split. What changes the payment is where the service happens: the place of service on the claim decides whether Medicare pays the office or the facility rate. Billing it with a same-day procedure? See modifier 25.

99213 compared with similar codes

How to choose

99214Office visitEstablished patient, moderate complexity

99214 requires moderate decision making in two of three elements or at least 30 minutes when selected by time. Prescription drug management may establish moderate risk, but risk alone does not establish moderate decision making.

99212Office visitEstablished patient, straightforward

99212 requires straightforward decision making or at least 10 minutes when selected by time. Choose 99213 for low decision making or at least 20 minutes.

99203New patient visitLow MDM or 30 minutes

99203 is for a new patient and requires at least 30 minutes when selected by time, versus 20 minutes for 99213. Check prior professional services from the practitioner or a same-specialty, same-subspecialty group member within three years.

99243Office consultationLow MDM, 30 minutes

99243 represents a requested office consultation when the payer recognizes consultation codes. Medicare does not recognize those codes; report the appropriate office visit level, such as 99213 when its established-patient criteria are met.

Codes related to 99213

Related codes aren’t interchangeable: bill the code that matches the service performed.

Where these rates come from

FeeBase calculates base physician payments from CMS work, practice-expense and malpractice RVUs, adjusted by each locality’s geographic indexes and the conversion factor. Services without a published rate are labeled, never given a made-up amount. Amounts are Medicare allowed amounts before claim adjustments: not a patient’s bill or a commercial rate.

CMS RVU26D · effective Oct 1, 2026 through the day before Jan 1, 2027

Open CMS sourceHow we calculate rates