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Level 3 Established Office Visit (99213)

This level of care is located “in the middle’ of the coding spectrum for office visits with established patients.  The 99213 is the second most popular choice for internists who selected this level of care for 41.78% of these encounters in 2014.   Usually the presenting problems are of low to moderate severity.  The reimbursement for this level of care is $73.40 and is worth 0.97 work RVUs

The documentation for this encounter requires TWO out of THREE of the following:

1)  Expanded Problem Focused History
2)  Expanded Problem Focused Exam
3)  Low Complexity Medical Decision-Making

Or 15 minutes spent face-to-face with the patient if coding based on time.  The appropriate documentation must be included.

Clinical Example...

This topic is covered in detail in of one of our web-based E/M coding courses.

Established Office Patients

Established Office Visits   Related Topics


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These are the most common patient encounters on the planet, so it's important to code correctly for these visits. Knowing the difference between a level 3 and level 4 established office patient can make a huge difference in your remibursement and income.  
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