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Evaluation and Management of an established patient where the provider of service meets two of the following three criteria: expanded problem, focused history expanded problem, focused exam low medical decision making. Service typically lasts 15 minutes.
CPT Code 99213 Office or Other Outpatient Visit
Office or other outpatient visit for the evaluation and management of an established patient, which requires two of these three key components:
- An expanded problem focused history
- An expanded problem focused examination
- Medical decision making of low complexity Documentation to support this service should include, but is not limited to the following: Medicare allows only the medically necessary portion of the visit. Even if a complete note is generated, only the necessary services for the condition of the patient at the time of the visit can be considered in determining the level of an E/M code.