Established Patient Office Visit – Moderate Service

CPT Code: 99213

Description: This code is used for established patient visits lasting about 15 minutes. It requires an expanded problem-focused history and exam, along with low complexity MDM.

Key Components:

• History: Expanded problem-focused
• Examination: Expanded problem-focused
• Medical Decision Making: Low complexity

It is commonly used for routine follow-ups and minor concerns.

Documentation Tips:

• Clearly record the patient’s current status, history, and exam findings.
• Provide a concise explanation of the medical decision-making process.
• If applicable, document the total time spent during the encounter.

Keep up to date with any changes in guidelines that may affect code selection.