CPT Code 99214: An Overview for Medical Practices

One of the services offered by medical practices is medical coding. There are numerous codes used in medical coding and one of the most important for medical practices is the Current Procedural Terminology (CPT) code as it is used to describe services rendered to a patient. One CPT code is 99214. This code describes a common level of care for an established patient that is frequently misunderstood and getting it correct is important for reimbursement of the claim and for coding compliance.

CPT Code: What Is It?

CPT codes are frequently referred to by the code number contained in the CPT system that details the service. However, it is important to understand that CPT codes are not diagnosis codes which are the codes used to describe the medical problem involveٓd in the service or procedure. CPT codes are maintained and developed by the American Medical Association (AMA). This coding system is a uniform system developed to allow medical professionals to communicate the services and procedures provided to a patient.

Insurance companies and even federal programs such as Medicare and Medicaid impose five-digit coding systems which hospitals, medical professionals, and other healthcare providers must use. These systems include billing codes for services such as office appointments, surgeries, and diagnostic tests. In this arena, the most frequently used codes are the so called Evaluation and Management (E/M) codes which include visit codes numbered 99202-99215. One such code is 99214.

What is CPT Code 99214?

CPT Code 99214 is for office or other outpatient visits for the evaluation and management of established patients. Established patients are patients who, within the last 3 years, have seen this doctor, or any doctor in the same specialty of the same group practice.

This code represents a history and exam that requires a moderate amount of medical decision-making complexity. In other words, this is not just a run-of-the-mill quick visit. In this one, the patient is most likely to have one or more chronic conditions, has a new problem of uncertain prognosis, has an acute illness that poses a danger to life or significant bodily functions, or a new problem. In these visits, the provider usually spends about 25 minutes of face-to-face time with the patient.

The Importance of 99214 in Medical Billing

There are a number of reasons why the code 99214 is very important in medical billing.

• 1 Level of Service: It is a higher level of service than 99212 and 99213, which means higher reimbursement. After considerable effort and cognitive work in dealing with the complex patient problems, this code should be used to ensure that your practice is paid accurately for the work involved.
• 2 Audit Risk: 99214 is the most audited code, and for good reasons. It is the most frequently used code with high reimbursement, which should be well documented. In the absence of proper documentation, the 99214 code can cause a lot of problems, such as payment denial, repayment of the amount, and in the worst case, a fine.
• Regulatory Compliance: Are you adhering to rules set by Medicare (CMS), Medicaid, and private payers, as well as laws like HIPAA?
• 3 Practice Efficiency: Knowing when and how to apply 99214 makes it easier to streamline the billing process. This helps avoid claim denials and the administrative cost associated with claims appeals and improves revenue cycle management.

Criteria Medical Practices Should Follow for the Use of 99214

The AMA provided additional guidance pertaining to the selection of E/M codes in 2021. Specifically for 99214 and other outpatient office visits, the level of the code is determined by either the amount of total time spent on the day of the encounter, or by the level of Medical Decision Making (MDM). You need only to satisfy one of these two elements.

1. Medical Decision Making (MDM)

MDM is the principal factor representing the level of the visit. The amount of MDM for a 99214 visit has to be of moderate complexity. This is determined by fulfillment of at least two of the three elements below.

A. Number and Complexity of Problems Addressed

This element concerns the health problems that are addressed/managed during the visit. In order to be moderate complexity these problems would typically include the following:

• One or more chronic illnesses with exacerbations, progression, or side effects of the treatment.
• Two or more stable chronic illnesses.
• One newly diagnosed problem of uncertain prognosis.
• One acute illness that has systemic symptoms.
• One acute complicated injury.

Example: A patient with stable hypertension and diabetes presents with cough and shortness of breath. The physician is balancing the management of the two chronic conditions and the diagnosis and treatment of the new acute respiratory condition.

Category one: Any combination of three of the following:

• Review of prior external notes from one unique source.
• Review of each unique test result.
• Ordering of each unique test.

Category two: Evaluation requiring an independent historian. An independent historian is someone (e.g., parent, guardian, spouse, caregiver) who presents a history, and the patient is unable to do so reliably.

Example: A provider is seeing a diabetic patient. During the visit, the provider checks recent labs (e.g., A1c, lipid panel), reviews notes from the patient’s recent visit with a cardiologist, and prescribes a new statin. This would meet the data review requirements for moderate MDM.

C. Risk of Complications and/or Morbidity or Mortality of Patient Management : This final element considers the risk from the patient’s condition and from the diagnostics or treatment modalities. For moderate MDM this includes:

Management of medication.

• Making the decision of performing minor surgical procedures with patient or procedural risk factors.
• Making the decision of performing elective major surgical procedures in the absence of patient or procedural risk factors.
• Diagnosis or treatment of the patient is considerably constrained due to social determinants of health.

Example: For example, there is a patient who has a severely infected skin with bacteria, and there is a need to prescribe a new antibiotic. The management of the prescription and the risks involved is what constitutes the moderate risk.

2. Total Time

Example: The second way to qualify for CPT code 99214 is based on total time. The provider must spend 30-39 minutes of total time on the day of the patient encounter.

Example: This time includes both face-to-face and non-face-to-face activities performed by the physician or other qualified healthcare professional. These activities can include:

• Preparing to see the patient (e.g., reviewing tests and records).
• Obtaining and/or reviewing a separately obtained history.
• Performing the medical examination and evaluation.
• Counseling and educating the patient, family, or caregiver.
• Ordering medications, tests, or procedures.
• Referring and communicating with other healthcare professionals (when not separately billed).
• Documenting clinical information in the electronic health record (EHR).
• Independently interpreting results (not separately billed) and communicating results to the patient.
• Care coordination (not separately billed).

If you are using time to justify the code, your documentation must clearly state the total time spent and provide a summary of the activities performed.

Scenarios Where Medical Practices Can Apply CPT code 99214

A 65-year-old patient is considering disease management. CPT code 99214 is a good code for some scenarios.

Scenario 1: Chronic Disease Management: A 65-year-old established patient with type 2 diabetes and hypertension returns for a follow-up. Recent lab work shows his A1c has increased from 7.2% to 8.5%, and his blood pressure is elevated. The physician spends 35 minutes reviewing the patient’s history, glucose logs, and lab results; discussing lifestyle modifications; adjusting his oral diabetes medication and adding a new hypertension medication; and documenting the encounter. The visit qualifies for 99214 based on both moderate MDM (two stable chronic illnesses with exacerbation) and total time.

Scenario 2: Acute Complicated Injury: Upon referral from a primary physician, a 40-year-old patient comes from a fall. The patient was bearing full weight at the time of the injury, and now the ankle is swollen and bruised. The patient is also reporting not being able to bear weight on the bruised ankle. The physician performs a detailed exam and sutures a sprain injury, prescribes an X-ray, and the physician performs suturing of the sprain injury. The physician performs primary treatment for pain control injuries. This acute complicated injury treatment and prescription drug management is taken care of, hence the coding 99214.

Scenario 3: New Problem with Uncertain Prognosis: A 50-year-old patient presents with a three-week history of pain and unintentional loss of weight. The cause is reported to be unclear. The provider performs a thorough history and physical exam, reviews prior records, and orders a comprehensive metabolic panel, CBC and an abdominal ultrasound; to the potential cause. This is diagnosing with new issues including unclear prognosis, and moderate MD is mainly what is represented.

Critical Documentation Requirements For 99214

Accurate and thorough documentation is negotiable when billing 99214. Documentation is the basis for supporting the claims, and claims represent the service level that has been supported. Payers in an audit review documentation to assess whether the visit fits the requirements of the code.

Your clinical documentation ought to reflect, at a minimum, the moderate complexity of MDM or the total time spent.

Documenting for Medical Decision Making.

If the billing is based on MDM, the note would specifically outline the elements of a moderate complexity.

1 Problems Addressed: Itemize each diagnosis or problem that was addressed during the visit. Use words like, “exacerbation,” “worsening,” “uncontrolled,” or “stable” to characterize the status of the chronic conditions. New problems could be described as “undiagnosed” or “with uncertain prognosis.”

2 Data Reviewed: Specify the tests, and records, or organized data that you reviewed. For example, you could say, “I reviewed the A1c and lipid panel from Quest Diagnostics on 12/1/2025” or “I reviewed the consultative note from Dr. Smith (Cardiology).” Also provide a list of tests that you ordered and if an independent historian was utilized, cite the name of the historian and the rationale for the previously provided history.

3 Risk: Document your management plan and this is the section that you would incorporate “prescription drug management,” if surgical or other definitive risks were to be considered as a social determinant of health. Merely documenting the writing of a prescription would not suffice as the note should reflect the cognitive work involved in weighing the alternatives, risks, and benefits.

Documenting time.

If billing is based on time, there should be a clear attestation.

Time Statement: One possible way of phrasing it is that “I spent a total of 35 minutes today on this patient’s care.”

Summary of Activities (Best Practice): Even though it is not a strict requirement from all payers, it is a best practice to briefly summarize how the time was spent. An example is that “This time included reviewing records, examining the patient, counseling on medication changes, and documenting in the EHR.” It adds a layer of support against audits.

Common Mistakes to Avoid with the 99214 CPT Code

Common mistakes in 99214 and the associated financial and compliance consequences:

– Upcoding: Increasing the difficulty level of a visit to a level 99214 when it only justifies a 99213. This often occurs when a patient presents with a single minor and stable problem.

– Downcoding: This occurs when a more complex visit is billed as a 99213. This often occurs because of the reluctance to associate the visit with an audit.

– Insufficient documentation This is when the note fails to provide sufficient detail to support a moderately complex MDM or total time spent. This is one of the more common reasons for an audit denial.

Cloning Notes: Copying from prior entries and pasting into new notes without customizing each visit. All notes pertaining to a visit must be differentiated from each other.

Miscalculation of Time: Including time spent by clinical staff (MAs taking vitals, etc.) in the total time calculation for the billing provider. Time spent by the billing provider (MD, DO, NP, PA) is the only time that counts.

Billing Based On Both MDM and Time: You must select one or the other to substantiate the code, not a combination of the two.

Tips for Optimizing Your Billing Process

Medical practices can take anticipatory steps to increase accuracy in billing 99214 and enhance their revenue cycle.

• ➤ Train physicians and other providers frequently on new CPT guidelines. Document opportunities in practice and incorporate them into educational sessions on documentation, and explain the requirements.
• ➤ Create EHR templates to assist providers in incorporating necessary information for MDM or time-based billing, Easy documentation of time attestations is provided by smart phrases, which can be used to make documentation more uniform.
• ➤ Schedule periodic internal audits of charts billed 99214. To identify areas of non-compliance and suggest improvements, a certified coder or senior provider should review a sample of records.
• ➤ There should be constant and continuous communication between clinical and billing staff. Coders can give insight on documentation, and providers can elaborate on clinical detail that affects code selection.
• ➤ There are slight variations between different insurance companies. Make sure you are updated on the policy directives from your major payers.