99214

Office or Other Outpatient Visit, Established Patient, Level 4

An outpatient encounter for an established patient, requiring a medically appropriate history and/or examination and moderate medical decision making, or when the encounter is based on total time, 30-39 minutes of total time is spent on the date of the encounter. This code is frequently used for follow-up care, management of chronic conditions, or evaluation of new problems in established patients.

Clinical Indications

  • Routine follow-up examination after treatment for a resolved or stable acute condition (e.g., pneumonia, fracture).
  • Management and monitoring of chronic stable conditions (e.g., hypertension, diabetes, asthma).
  • Post-operative follow-up visits outside the global surgical period, or for unrelated conditions.
  • Evaluation of symptoms recurring after previous treatment, not requiring emergency intervention.
  • Monitoring effectiveness of ongoing treatment and potential side effects for non-malignant conditions.

Procedure Steps

  1. Patient intake, including review of systems and interval history since the last visit.
  2. Performance of a medically appropriate physical examination relevant to the presenting problem and follow-up.
  3. Assessment of the patient's current health status, progress of chronic conditions, and response to treatment.
  4. Review and interpretation of diagnostic test results (e.g., labs, imaging) as necessary.
  5. Development or modification of the patient's care plan, including medication adjustments, referrals, or lifestyle recommendations.
  6. Counseling and education provided to the patient regarding their condition, treatment, and preventive care.
  7. Thorough documentation of the encounter, including history, examination findings, assessment, plan, and time spent (if time-based coding is used).

Coding Guidelines

  • Code selection for 99214 is based on either the level of medical decision making (MDM) or the total time spent on the date of the encounter. For 99214, the MDM must be of moderate complexity, or 30-39 minutes of total time must be met.
  • The diagnosis code Z09 ('Encounter for follow-up examination after treatment for conditions other than malignant neoplasms') should be used as the primary reason for the encounter when the purpose of the visit is a follow-up examination after treatment for a condition that is not cancer.
  • The specific condition(s) for which the patient is being followed up (e.g., hypertension, diabetes, osteoarthritis) should be reported as additional diagnosis codes.
  • Do not use this code for routine post-operative care provided within the global surgical period, as those services are typically bundled into the surgical package.
  • Documentation must clearly support the level of service billed, detailing the history, examination, medical decision making components, or the total time spent with the patient and/or family/caregiver.

Associated ICD-10 Codes