99213 Established patient visit

by  Codapedia
July 28th, 2016

There are sample audited notes in resource section.

99213 is an established patient visit which requires 2 of 3 of the following components:

An expanded, problem focused history, which is 1-3 HPI elements and 1 system in ROS reviewed 
An expanded, problem focused exam, which is 6 bullets from 1997 exam or limited exam of 2-7 body areas/organ systems.  Some payers and auditors use 2-4 body areas/organ systems as an expanded problem focused exams, but this is not in the original guidelines.
Low MDM, which could be one worsening problem, two stable problems or a new, acute uncomplicated illness.  These are only examples, there are many ways to reach low MDM.

See the other articles in Codapedia on auditing and the Documentation Guidelines

Resources: Sample, audited 99213 notes (pdf)  


99213 Established patient visit. (2016, July 28). Find-A-Code Articles. Retrieved from https://www.findacode.com/articles/99213-established-patient-visit-28106.html

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