99213 CPT Code: Exploring the Wound Care Code & Its Sisters

As a wound care provider, you’re no doubt familiar with CPT codes. One you likely use often is the 99213 CPT code, as it deals with established patients.

Given the nature of ongoing wound care, many of your patients probably have regular follow-up visits for their injuries. However, choosing between 99213 and the family of related CPT codes  can sometimes be tricky. Keep reading to learn more about the 99213 CPT code and the distinctions among its sister codes.

What Are CPT Codes?

Current Procedural Terminology (CPT) is a standardized coding system developed and maintained by the American Medical Association (AMA). It includes a vast array of codes covering a wide range of diagnostic and medical services—from simple office visits to complex surgical procedures.

The CPT code set, which consists of five-digit numeric codes, is updated annually to reflect changes in medical technology and practice and is widely used by physicians, hospitals, and other healthcare organizations.

The CPT code set is useful for:

• Communication. It provides a common language for healthcare providers to communicate with each other, payers (insurance companies), and other stakeholders about the services they provide.
• Billing and reimbursement. It enables accurate and consistent billing for healthcare services, facilitating reimbursement from insurance companies and government programs like Medicare and Medicaid.
• Data collection and analysis. From a broader viewpoint, it’s used to track healthcare utilization, analyze treatment patterns, and conduct research.

Why Coding Is Important

Coding practices such as CPT play an important role in:

• Fair compensation. Proper coding ensures that healthcare providers receive fair and appropriate reimbursement for the services they provide to patients.
• Practice viability. Accurate coding is essential for the financial stability and sustainability of wound care practices.
• Regulatory adherence. Adhering to coding guidelines helps ensure compliance with complex regulations and minimizes the risk of audits and penalties from payers (like insurance companies, Medicare, and Medicaid).  
• Legal and ethical obligations. Accurate coding is an ethical and legal obligation for healthcare providers.
• Improving patient care. Accurate coding contributes to high-quality data that can be used to track treatment outcomes, identify areas for improvement in patient care, and conduct research to advance wound care practices.
• Public health. Accurate coding data helps public health agencies understand the prevalence and trends of various health issues (such as wound types), which can inform public health initiatives and resource allocation.
• Streamlining billing. Accurate coding helps streamline the billing process, reducing administrative burdens and improving cash flow for healthcare providers.
• Reducing claim denials. By minimizing coding errors, practitioners can reduce the number of denied claims, saving time and resources in dealing with these claims.

Thus,  the value of coding is not just about billing; it’s fundamental to the successful operation of a wound care practice by ensuring fair reimbursement, compliance with regulations, improved patient care, and better health outcomes.

99213 CPT Code: A Breakdown

1. What Is the 99213 CPT Code?

CPT code 99213: Established patient office or other outpatient visit, 20-29 minutes

The AMA provides the following 99213 CPT code description: “[An] office visit for an established patient with a stable chronic illness or acute uncomplicated injury.”

This level of medical service generally involves a few things.

• A medically appropriate history and/or examination: This could include a detailed history of the present illness, a review of systems, and a problem-focused or expanded problem-focused physical examination.
• A low level of medical decision-making: This might include a limited number of diagnoses or management options, the review of a limited amount and complexity of data, and a low risk of complications and/or mortality.
• An appropriate amount of care time: Typically, a physician will spend 20-29 minutes of total face-to-face time with the patient on the date of the encounter.

The 99213 CPT code can be used by a variety of healthcare providers, including:

• Physicians such as Doctors of Medicine (MDs)   or Doctors of Osteopathic Medicine (DOs) in various specialties
• Nurse practitioners (NPs)
• Physician assistants (PAs)

Essentially, any qualified healthcare provider who provides evaluation and management services to established patients in an outpatient setting can potentially use the 99213 code, provided the services meet the specified criteria. Though the specific qualifications and scope of practice for healthcare providers may vary depending on state and local regulations.

2. Documentation Requirements

Thorough documentation is essential for supporting the use of the 99213 CPT code. Documentation should be clear, concise, easy to understand, and should support the level of medical decision-making required of this code. Use specific and descriptive language to accurately reflect the services provided, and ensure that documentation adheres to all relevant coding guidelines and regulations.

Some key elements that should be present in the patient’s medical records include:

• Chief complaint. Clearly document the patient’s primary reason for the visit.
• History of present illness (HPI). Provide a detailed description of the patient’s current symptoms, including:
  • Onset
  • Duration
  • Location
  • Severity
  • Character
  • Aggravating and alleviating factors
• Review of systems (ROS). Document a review of systems relevant to the patient’s chief complaint and overall health status.
• Past, family, and social history. Briefly document relevant aspects of the patient’s past medical history, family medical history, and social history (e.g., smoking, alcohol use, occupation).
• Physical examination. Document a problem-focused or expanded problem-focused physical examination, focusing on the systems relevant to the patient’s chief complaint.
• Assessment and plan. Clearly document the assessment of the patient’s condition. An outline for the plan may include:
  • Diagnoses
  • Medications
  • Tests or procedures
  • Patient education
  • Follow-up plan
• Time spent. Document the total time spent with the patient on the date of the encounter (typically 20-29 minutes for this code).

3. Common Coding Challenges

The following coding challenges may be applicable to any CPT code, but for now, we’ll focus on the 99213 CPT code. Be sure to avoid these common challenges.

• Upcoding: Billing for a higher level of service than you actually provided, for example, billing for 99213 when the level of service more accurately reflects a lower-level code (e.g., 99212). Doing so can lead to significant financial penalties, including fines and potential exclusion from government health programs.
• Downcoding: Billing for a lower level of service than you actually provided, for example, billing for 99213 when the level of service more accurately reflects a higher-level code (e.g., 99214). This can result in underpayment for your services, impacting the financial viability of the clinic or practice.
• Inadequate documentation: Insufficient or poorly documented medical records can make it difficult to justify the use of the 99213 code during an audit. For example, missing or incomplete documentation of time spent with the patient, history, examination, or medical decision-making. Consequences include increased risk of claim denials and potential for audits.
• Misinterpreting coding guidelines: Misunderstanding or misapplying the specific criteria for the 99213 code, such as the requirements for time spent, history, examination, and medical decision-making. This can lead to incorrect coding and potential reimbursement issues, among other consequences.
• Missing out on ongoing education: Failure to stay updated on the latest coding guidelines and regulatory changes can increase the risk of coding errors and non-compliance, resulting in inaccurate billing and potential penalties.

4. CPT Code 99212 vs 99213 vs 99214

CPT codes 99212, 99213, and 99214 are all used to bill for established patient office visits. These codes are sometimes confused because they are very similar; however, they represent different levels of complexity and require varying degrees of medical decision-making, time spent with the patient, and documentation.

99212 CPT Code

• Description from the AMA: “[An] office visit for an established patient with a self-limited problem that is treated with an over-the-counter (OTC) medication.”
• Complexity: Straightforward to low level of medical decision-making.
• Time: Typically 10-19 minutes of total time spent with the patient.

99213 CPT Code

• Description from the AMA: “[An] office visit for an established patient with a stable chronic illness or acute uncomplicated injury.”
• Complexity: Low to moderate level of medical decision-making.
• Time: Typically 20-29 minutes of total time spent with the patient.

99214 CPT Code

• Description from the AMA: “[An] office visit for an established patient with a progressing illness or acute injury that requires medical management or potential surgical treatment.”
• Complexity: Moderate level of medical decision-making.
• Time: Typically 30-39 minutes of total time spent with the patient.

Following is a summary table of the distinctions between the 99212, 99213, and 99214 CPT codes.

Aspect	99212	99213	99214
Complexity	Low	Low to moderate	Moderate
Time	10-19 min	20-29 min	30-39 min
History	Problem-focused	Expanded problem-focused	Detailed
Examination	Problem-focused	Expanded problem-focused	Detailed
Medical Decision-Making	Straightforward to low	Low to moderate	Moderate

5. Tips for Accurate Coding

To ensure you are using the 99213 CPT correctly—and by extension, all CPT codes—be sure you:

• Understand the criteria. Thoroughly familiarize yourself with the specific criteria for the 99213 CPT code.
• Use accurate documentation. Clearly document all necessary aspects of the code, including time spent, appropriate history, examination, and level of medical decision-making.
• Stay updated on coding guidelines. Regularly review coding guidelines and regulations for any updates or changes. Also consider  attending coding workshops and seminars to stay current on the latest information.
• Use coding resources. Consult with experienced coders or coding experts for guidance. In addition, take advantage of coding manuals and online resources for clarification and support.
• Conduct internal audits. Regularly review patient medical records and coding practices to identify and correct any potential errors.
• Implement a coding compliance program. Establish a system for tracking and monitoring coding accuracy and provide ongoing education with  training to teach staff oding guidelines and best practices.

Accuracy Is the Name of the Coding Game

Accurate coding, particularly for established patient office visits like the 99213 CPT code, is critical for healthcare providers. It ensures fair reimbursement, maintains compliance with regulations, and supports data-driven improvements in patient care.

By understanding the criteria for each code, documenting thoroughly, and staying updated on coding guidelines, you can minimize coding errors, optimize reimbursement, and ultimately enhance the quality of care you provide.