What your 99213 actually pays: Medicare's 2026 rate, and the downcode connection

The level-3 established-patient visit is the most common office-visit code in all of medicine. In behavioral health it plays a second role: it is the code a payer quietly moves your 99214 to when it decides, without telling you, that your visit did not support a higher level.

The code, and why it matters for prescribers

CPT code 99213 is the level-3 established-patient office visit: 20 to 29 minutes of total time, or medical decision-making (MDM) classified as low complexity. For a psychiatric mental health nurse practitioner (PMHNP) or psychiatrist, this is the floor for almost any visit that touches a prescription: renewing a stable medication counts as low complexity on its own. A stable follow-up with no dose change is usually a 99213; the moment the visit adds a new problem, a dose change, or a second medication being actively managed, it typically crosses into 99214.

What Medicare pays in 2026

Medicare pays $95.19 nationally for 99213 in 2026, up from $88.95 in 2025, a 7.0% increase. The number underneath that move is the Medicare conversion factor, a single dollar multiplier that CMS applies to every code on the physician fee schedule. It fell for five straight years, from a peak of $36.09 in 2020 to $32.35 in 2025, before this year's rule reversed course: $33.40 for 2026, a 3.26% increase. E/M codes were explicitly exempted from a separate 2.5% cut CMS applied to roughly 7,700 other codes in the same rule.

The downcode gap

99213 has a second identity: it is the landing spot when a payer downcodes a 99214. Starting in 2019, UnitedHealthcare began quietly adjusting high-level evaluation and management (E/M) claims down to a lower level instead of denying them outright, a practice later flagged by the American Academy of Family Physicians. Cigna formalized a similar review, Policy R49, covering 99214 and 99215 starting October 1, 2025. The gap between the two Medicare rates in 2026 is $95.19 versus $135.61, a difference of $40.42 per visit. In a practice billing 150 level-4 visits a day, a 10% downcode rate quietly costs roughly $135,000 a year, with no denial ever appearing in the practice management system to flag it.

What commercial payers pay

PayerPrice shows national average commercial rates for 99213 from $82.03 (Aetna) to $101.25 (Cigna) as of August 2026, all close to the Medicare benchmark. Because 99213 is also the downcode destination, a payer paying you a 99213-level amount on a claim you billed as 99214 will not show up as an error anywhere in a typical remittance report. It shows up only when you compare the code you billed against the code that was actually paid.

The so-what

• Run a 99213-to-99214 ratio. For a pure medication-management panel, 99214 should be the majority code among established patients. If your ratio shifted after October 2025 or after a payer contract renewal, pull a sample of explanation-of-benefits (EOB) documents and compare the code you billed to the code that was paid.
• Do not assume every low payment is a downcode. Verify place of service, modifiers, and credentialing status first. A genuinely low-complexity visit correctly billed as 99213 is not a problem to fix.