Office Visit, Established Patient, Low Complexity (20 to 29 min)
CPT 99213 is the second most commonly billed office visit code in America, used over 71.5 million times per year across 19.1 million Medicare beneficiaries alone. It covers a 20 to 29 minute visit with low complexity medical decision making for an established patient. Providers charge an average of $179.97 for this visit, but Medicare pays only $95.19 for the physician fee in an office setting (1.9x markup). In a hospital setting, the physician fee drops to $57.45, but the hospital adds a separate facility fee on top.
CPT 99213 at a Glance
- Average provider charge: $179.97
- Medicare physician fee (office): $95.19
- Medicare physician fee (hospital): $57.45 + separate facility fee
- Typical markup: 1.9x over Medicare office rate
- Visit duration: 20 to 29 minutes
- Decision complexity: Low
- Patient type: Established (seen before)
- Beneficiaries (2023): 19.1 million
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How the Medicare Rate Is Calculated
Medicare does not set prices arbitrarily. Every procedure is valued using Relative Value Units (RVUs) across three components, then multiplied by a national conversion factor of $33.4009 (2026). Here is the exact math for a 99213 visit:
| Component | What It Covers | Office (Non-Facility) | Hospital (Facility) |
|---|---|---|---|
| Work RVU | Physician time, skill, and judgment | 1.30 | 1.30 |
| Practice Expense RVU | Rent, staff, equipment, supplies | 1.46 | 0.33 |
| Malpractice RVU | Professional liability insurance | 0.09 | 0.09 |
| Total RVU | 2.85 | 1.72 | |
| x $33.4009 | 2026 conversion factor | $95.19 | $57.45 |
Medicare Rate by State
Medicare adjusts the national rate based on your location using Geographic Practice Cost Indices (GPCIs). The same 99213 visit pays differently in each state, ranging from about $85 in Arkansas to $113 in Alaska (a 34% spread).
Medicare Rate by State (2026)
Medicare adjusts payments by location using Geographic Practice Cost Indices (GPCIs). Select your state to see the adjusted rate.
Sample State Rates (Office Setting)
| State | Medicare Pays | Avg. Charge | Markup |
|---|---|---|---|
| Texas (Austin) | $96.09 | $179.97 | 1.9x |
| California (Los Angeles) | $103.67 | $179.97 | 1.7x |
| New York (Manhattan) | $106.07 | $179.97 | 1.7x |
| Florida (Fort Lauderdale) | $97.50 | $179.97 | 1.8x |
| Ohio | $88.55 | $179.97 | 2.0x |
| Mississippi | $85.48 | $179.97 | 2.1x |
| Arkansas | $84.59 | $179.97 | 2.1x |
| Alaska | $113.11 | $179.97 | 1.6x |
Rates shown are for the non-facility (office) setting using 2026 GPCIs and the $33.4009 conversion factor. The average provider charge of $179.97 is the 2023 national average from CMS utilization data. Actual charges vary by provider.
What Insured Patients Actually Pay for a 99213 Visit
If you have health insurance, you do not pay the provider's full charge of $179.97. Your insurer has a negotiated rate with the provider, typically 120% to 200% of the Medicare rate. For a 99213 visit, that negotiated rate is usually $115 to $190. What you owe depends on your plan design:
| Your Situation | What You Likely Pay | How It Works |
|---|---|---|
| Copay plan (deductible met or N/A) | $20 to $50 | Flat copay per specialist or primary care visit |
| Coinsurance plan (deductible met) | $23 to $38 | 20% of the negotiated rate ($115 to $190) |
| High-deductible plan (deductible NOT met) | $115 to $190 | You pay the full negotiated rate until your deductible is met |
| Medicare Part B | $19.04 | 20% of the Medicare-approved amount ($95.19) |
| Medicaid | $0 to $5 | Minimal or no cost-sharing in most states |
Should You Use Insurance or Pay Cash?
If you have a high-deductible health plan (HDHP) and have not met your deductible, you are paying the full negotiated rate for every visit. For a 99213 office visit, this is typically $115 to $190 through insurance. Many providers offer a cash-pay rate of $80 to $130 for the same visit, which can be cheaper.
When Cash-Pay Wins
- You are unlikely to meet your deductible this year (low expected utilization)
- The provider's cash rate is below the insurer's negotiated rate
- You want to see an out-of-network provider without a referral
- Your visit is a straightforward follow-up with minimal complexity
When Using Insurance Wins
- You are close to meeting your annual deductible
- You expect significant medical expenses later this year
- Your copay is less than the cash-pay rate
- You need the visit documented for insurance continuity of care
Common Billing Problems with 99213
Upcoding from 99213 to 99214
This is the most common billing issue with 99213. A 99213 pays $95.19 while a 99214 pays $135.61, a 42% jump. Some providers routinely code visits at the higher level to increase revenue. If your visit was a brief follow-up lasting 20 to 25 minutes with a single straightforward issue, it should be a 99213, not a 99214. Check your bill and request the visit notes if the code seems too high for what happened during your appointment.
Default coding: every follow-up billed as 99213
99213 is often treated as the "default" code for routine follow-up visits. Some practices auto-code every established patient follow-up as a 99213 regardless of actual complexity or time spent. If your visit was very brief (under 20 minutes) and involved a single straightforward issue (like a medication refill check or a simple lab result review), it may more accurately be a 99212, which costs less. On the other hand, if your provider spent 30 or more minutes and addressed multiple issues, your visit may have been undercoded and could legitimately be a 99214.
Downcoding from 99214 to 99213
If your doctor spent 30 or more minutes with you, addressed multiple problems, or ordered several tests, the visit may warrant a 99214. Downcoding to 99213 is less common than upcoding, but it can happen when providers use templates that default to a lower level or when documentation does not fully capture the work done. This matters if you are a Medicare patient because your 20% coinsurance is lower on a 99213 ($19.04 vs $27.12), but it can affect your care record and future visit expectations.
Facility fee on top of the physician charge
If your doctor's office was acquired by a hospital system (increasingly common), your visit may now be billed as a hospital outpatient visit. The physician charge drops from $95.19 to $57.45, but the hospital adds a facility fee of $100 to $300, making the total higher. Check your bill for a separate "facility fee" or "outpatient hospital" line item. If this is new since your doctor joined a hospital network, this is the cause.
Time-based billing errors
Since 2021, E/M office visits can be coded based on either medical decision making or total time. If time-based, 99213 requires 20 to 29 minutes of total time (including chart review and care coordination, not just face-to-face time). If your visit was 18 minutes total, it should be coded as 99212, not 99213. If it was 32 minutes, it could be a 99214. Your patient portal may show appointment duration that contradicts the billed code.
Related Office Visit Codes
Frequently Asked Questions
How much does CPT 99213 cost without insurance?
Without insurance, an office visit billed under CPT 99213 costs $100 to $250 depending on the provider and location. The national average charge is $179.97. Many providers offer a cash-pay discount of 20 to 40%, bringing the price closer to $80 to $130. For comparison, Medicare pays $95.19 for this visit in an office setting.
What is the difference between 99213 and 99214?
CPT 99213 is a 20 to 29 minute office visit requiring low complexity medical decision making. CPT 99214 is a 30 to 39 minute visit requiring moderate complexity medical decision making. The 2026 Medicare rate for 99213 is $95.19 versus $135.61 for 99214, a 42% difference. If your visit lasted 30 minutes or more and addressed multiple problems, it may warrant a 99214. If it was under 30 minutes with a single straightforward concern, 99213 is the correct code.
How much does insurance pay for a 99213 office visit?
Commercial insurance plans typically negotiate rates between 120% and 200% of Medicare, meaning they pay roughly $115 to $190 for a 99213 visit. Your out-of-pocket cost depends on your plan: with a copay plan you may pay $20 to $50, with coinsurance you pay 10 to 30% of the allowed amount, and if your deductible is not met you pay the full negotiated rate.
Why is every follow-up visit coded as 99213?
CPT 99213 is often treated as the "default" code for routine follow-up visits. Some providers auto-code every established patient follow-up as a 99213 regardless of actual complexity or time spent. If your visit was very brief (under 20 minutes) and involved a single straightforward issue, it may more accurately be a 99212. Conversely, if your visit lasted 30 or more minutes and addressed multiple concerns, it could be a 99214. Ask to review your visit notes and compare the documented time and complexity to the code definitions.
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