CPT 99213

In plain terms: A routine established-patient visit for a problem of low-to-moderate complexity — for example, checking in on one or two stable chronic conditions like well-controlled hypertension or diabetes, or evaluating a new minor issue such as a cough or ankle sprain. Total visit time typically runs about 20 to 29 minutes, and documentation should show the problem(s) addressed, any data reviewed (such as a lab result), and a low risk of complications from the plan of care. It is one of the most frequently billed services in all of medicine. Think of a routine follow-up for one or two stable conditions — your doctor reviews your blood-pressure readings or diabetes numbers and renews or tweaks a medication — or a straightforward new problem like a sinus infection or urinary tract infection that needs a prescription. "Low-to-moderate complexity" means the problems are well understood and the treatment carries limited risk; the doctor is not juggling several serious unknowns. You'll typically see CPT 99213 on a bill or explanation of benefits (EOB) when a clinician performs or bills for this service.

On traditional Medicare, you typically owe 20% coinsurance — about $17.79 of the office amount above — once your annual Part B deductible is met. Supplemental coverage (Medigap, Medicaid, or a retiree plan) often picks up that share. With private insurance, your cost depends on your plan's negotiated rate, deductible, and copay — the exact split is on your explanation of benefits (EOB), not the provider's bill.

There's no single "correct" price to check your bill against, but three checks narrow it down. First, does the code match the visit you remember? Visit codes come in levels, and the level should track how much the clinician had to sort out: a quick recheck of one stable problem belongs at a low level, while a long visit working through several new or worsening problems belongs higher. Billing a higher level than the visit supports is called "upcoding" — it's the most common mismatch, and you can ask the billing office for the visit notes that back up the code. Second, compare the charge to the Medicare office amount here, $88.95: commercial plans typically pay 1× to 2.5× that, so a charge far outside that range is worth questioning. Third, request an itemized bill and check it against your explanation of benefits (EOB) for duplicate charges or services you didn't receive. If something still looks off, ask the billing office to explain, and escalate to your insurer if it isn't resolved.

There's no single price — every commercial insurer negotiates its own rate, and the Medicare amount is the benchmark those negotiations anchor to. Plans commonly pay between roughly 1× and 2.5× Medicare for physician services: at 1.5× the office amount here would be $133.43, at 2× it would be $177.90 — illustrative multiples, not a quote. Your explanation of benefits (EOB) has the actual negotiated rate.

Many practices offer a self-pay rate at or near the Medicare office amount of $88.95, since it avoids billing overhead and claim denials — but cash pricing is set by each practice, not CMS. Ask for the self-pay price before your visit and compare it against what you'd owe under your insurance plan.