CPT Code 99213 Guide and 99213 Reimbursement Rates

Learn about CPT Code 99213 for Evaluation and Management of an established patient in your practice.  This guide will teach you what defines CPT code 99213, what distinguishes it from other codes, and will also give you information about 99213 reimbursement rates for insurance.

CPT Code 99213 Definition

The American Medical Association (AMA) describes the 99213 CPT® procedure code as follows:

Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three components to be present in the medical record:

  • An expanded problem focused history
  • An expanded problem focused examination
  • Medical decision making of low complexity

Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 15 minutes face-to-face with the patient and/or family. 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.

Which evaluation and management code between 99212, 99213, 92214, and 99215 correspond to the complexity and risk for that treatment situation: low for code 99213, moderate for 99214, and high for 99215.

You want to select 99213 when two of the three components of medical treatment are met and the complexity of treatment is low.  When the complexity increases, the timeline for treatment increases, as does reimbursement rates, and so you’d be best to bill with a E/M cpt code that is of higher complexity like 99214 or 99215.

If you are unsure which code to use, be it 99213, 99214, or otherwise, feel free to reach out to us at TheraThink to get help with your mental health insurance billing.

Established Client Psychiatry Medicare Rates for 2019 and 2020

CPT Code 99213 Reimbursement Rates

It’s important to note that CPT Code 99213 reimbursement rates vary by location, insurance company, network status, panel, license, and more.  Rates quoted here are example rates that help show generally differing rates across different insurance companies.

99213 Medicare Reimbursement Rates:

CPT CodeService TimeRate
9921210 minutes$40.61
9921315 minutes$68.10
9921425 minutes$101.21
9921540 minutes$136.57

Other Medicare rates for CPT code 99213 are $81.62, in WA in King County, so it depends on the locality.  Source

99213 Medicaid Reimbursement Rates:

CPT CodeService TimeRate
9921210 minutes$31.36
9921315 minutes$43.23
9921425 minutes$66.80
9921540 minutes$99.95

Source

99213 Commercial Insurance Reimbursement Rates According to Medicare

Here are the rates that Medicare believes are the commercial insurance rates for these services (this is not the Medicare rate for 99213):

CPT CodeService TimeRate
9921210 minutes$90
9921315 minutes$90
9921425 minutes$90
9921540 minutes$148

Source

It’s important to note that these rates are adjusted down and reflect what Medicare has deemed are average rates for most psychiatrists across the United States.  These rates are adjusted by Medicare.

Some insurance companies only pay 15% over the Medicaid rate in their state, whereas others pay 45%, 60%, 80%, 85% on top of their state’s medicaid rate.

You can see these rates vary across insurance companies.  It’s important to keep this in mind when working on your mental health insurance credentialing applications.  Ask colleagues about rates if you dare, or reach out for help from us about suggestions!

Evaluation and Management Codes:  New vs Established Clients

Unlike 99212 through 99215, 99202 through 99205 describe newly established clients being seen for evaluation and management services.  Code 99213 should only be used with established clients you have already seen for an intake session (CPT Code 90792).

Getting Help Billing

Is all of this gibberish?  We established a mental health billing service at TheraThink to help you stay away from all this jargon so you can focus on what you do best.  Reach out now for more information on our services.

 

Sources:

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