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Code Description
Office or other outpatient visit for the evaluation and management of an established patient
Status
Active
Category
Evaluation and Management
Year
2023
Carrier Number
12345
Locality
01
HCPCS Code
99213
Modifier
None
Non-Facility Fee Schedule Amount
$72.00
Facility Fee Schedule Amount
$60.00
PCTC Indicator
No
Status Code
A
Multiple Surgery Indicator
2
50% Therapy Reduction (Non-Facility)
No
50% Therapy Reduction (Facility)
No
OPPS Indicator
1
OPPS Non-Facility Fee Amount
$0.00
OPPS Facility Fee Amount
$72.00
Notes
Typically requires at least 2 of these 3 key components: Expanded problem focused history; Expanded problem focused examination; Medical decision making of low complexity.
| ICD-10 Code | Description | Coverage Status |
|---|---|---|
| I10 | Essential (primary) hypertension | Covered |
| E11.9 | Type 2 diabetes mellitus without complications | Covered |
| J45.909 | Unspecified asthma, uncomplicated | Covered |
| M54.50 | Low back pain, unspecified | Covered |
| Z00.00 | Encounter for general adult medical examination without abnormal findings | Not Covered |
| Primary Code | Secondary Code | Effective Date | Deletion Date | Modifier | Rationale |
|---|---|---|---|---|---|
| 99213 | 93000 | 01/01/2015 | — | 59 | Separate procedure |
| 99213 | 96372 | 01/01/2017 | — | 25 | Significant, separately identifiable E/M service |
| 99213 | 11719 | 01/01/2016 | 01/01/2020 | 59 | Separate procedure (deleted) |
| 99213 | G0463 | 01/01/2019 | — | 25 | Significant, separately identifiable E/M service |
| Taxonomy Code | Classification | Specialization | Typical CPT Range | Details |
|---|---|---|---|---|
| 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | 99201–99499 | |
DefinitionFamily Medicine is the medical specialty which is concerned with the total health care of the individual and the family. It is the specialty in breadth which integrates the biological, clinical, and behavioral sciences. NotesScope of practice is not limited to age, sex, organ system, or disease entity. Includes preventive medicine and health maintenance. Display NameFamily Medicine SectionAllopathic & Osteopathic Physicians |
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| 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | 99201–99499 | |
DefinitionA physician who provides long-term, comprehensive care in the office and the hospital, managing both common and complex illness of adolescents, adults and the elderly. NotesInternists are trained in the diagnosis and treatment of cancer, infections, and diseases affecting the heart, blood, kidneys, joints, and digestive, respiratory and vascular systems. Display NameInternal Medicine SectionAllopathic & Osteopathic Physicians |
||||
| 208600000X | Allopathic & Osteopathic Physicians | Surgery | 10021–69990 | |
DefinitionA general surgeon has expertise related to the diagnosis - preoperative, operative and postoperative management - of surgical disorders of the gastrointestinal tract, abdomen, breast, skin and soft tissue, and endocrine system. NotesGeneral surgeons also deal with diseases involving the skin, breast, soft tissue, trauma, peripheral vascular surgery, and hernias and perform endoscopic procedures. Display NameSurgery SectionAllopathic & Osteopathic Physicians |
||||
| 208800000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 20005–29999 | |
DefinitionAn orthopaedic surgeon is trained in the preservation, investigation and restoration of the form and function of the extremities, spine and associated structures by medical, surgical and physical means. NotesAn orthopaedic surgeon is involved with the care of patients whose musculoskeletal problems include congenital deformities, trauma, infections, tumors, metabolic disturbances and degenerative diseases. Display NameOrthopaedic Surgery SectionAllopathic & Osteopathic Physicians |
||||
| 261QM1300X | Ambulatory Health Care Facilities | Multi-Specialty | 99201–99499, 10021–69990 | |
DefinitionAn entity, facility, or distinct part of a facility providing diagnostic, treatment, and prescriptive services related to a variety of medical specialties. NotesMulti-specialty clinics or group practices are typically composed of practitioners representing a variety of medical specialties who share common facilities and administrative support. Display NameMulti-Specialty Clinic/Center SectionAmbulatory Health Care Facilities |
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| HCPCS/CPT Code | MUE Value | Adjudication Indicator | MUE Rationale |
|---|---|---|---|
| 99213 | 1 | 1 | Medical reason |
| 93000 | 2 | 2 | Date of service limitation |
| J3420 | 4 | 3 | Once in a lifetime |
| 96372 | 1 | 1 | Medical reason |
| 11719 | 10 | 2 | Date of service limitation |