99214

Office or other outpatient visit for the evaluation and management of an established patient

This code represents an office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and a moderate level of medical decision making (MDM). When time is used to select the level of the E/M service, 30-39 minutes of total time must be spent on the date of the encounter. This total time includes both face-to-face and non-face-to-face time personally spent by the physician or other qualified healthcare professional on the date of the encounter, dedicated to the patient's care.

Clinical Indications

  • Management of one or more chronic illnesses with exacerbation, progression, or side effects of treatment, requiring moderate medical decision making.
  • Evaluation and management of a new problem to the examiner that is moderate in severity, requiring moderate medical decision making.
  • Management of two or more stable chronic illnesses, where the overall complexity of decision making rises to a moderate level due to multiple treatment options, data review, or risk.
  • Follow-up care for post-operative complications or significant new symptom complexes in an established patient that require moderate medical decision making.
  • Patients with complex social determinants of health that significantly impact their medical care and necessitate moderate decision making in their management plan.
  • When a single, acute complicated injury or illness is managed, requiring moderate medical decision making.

Procedure Steps

  1. **History Taking**: Elicit and document a medically appropriate history, including the chief complaint, history of present illness, relevant review of systems, and past, family, and/or social history, as guided by the patient's presenting problem(s).
  2. **Physical Examination**: Perform and document a medically appropriate physical examination, focusing on areas relevant to the patient's presenting problem(s) and overall health status.
  3. **Medical Decision Making (MDM)**: This is the primary component for code selection (unless time is used). For a moderate MDM level, the service must meet or exceed at least two of the three following elements:
  4. **Number and Complexity of Problems Addressed**: This typically involves evaluation of one or more chronic illnesses with exacerbation, progression, or side effects of treatment; or two or more stable chronic illnesses; or one new problem to the examiner that is moderate in severity; or one acute complicated injury/illness.
  5. **Amount and/or Complexity of Data to be Reviewed and Analyzed**: Moderate. This may include review of prior external notes, review of results of undiagnosed tests, ordering and review of various tests (e.g., imaging, laboratory, physiologic), or discussion of management with external providers.
  6. **Risk of Complications and/or Morbidity or Mortality of Patient Management**: Moderate. This involves decisions regarding minor surgery with identified risk factors, elective major surgery without identified risk factors, prescription drug management, decision regarding diagnostic procedure with moderate risk to the patient, or management of a chronic illness with exacerbation.
  7. **Counseling and/or Coordination of Care**: Provide appropriate counseling to the patient and/or family regarding diagnoses, treatment options, risks, benefits, and prognosis. Coordinate care with other healthcare professionals as necessary.
  8. **Documentation**: Create a comprehensive medical record entry that accurately reflects the history, physical exam findings, assessment, plan of care, and explicitly supports the moderate level of medical decision making or the total time spent for code selection.

Coding Guidelines

  • **Documentation Requirements**: The medical record must clearly support a moderate level of Medical Decision Making (meeting at least two out of three MDM elements at the moderate level) or document 30-39 minutes of total time spent on the date of the encounter.
  • **Time-Based Coding**: When using time for code selection, total time includes all physician/qualified healthcare professional activities on the date of the encounter, both face-to-face and non-face-to-face (e.g., preparing to see the patient, obtaining/reviewing history, performing exam, counseling, ordering medications/tests, referring, documenting, care coordination).
  • **MDM-Based Coding**: The level of MDM is determined by the number and complexity of problems addressed, the amount and/or complexity of data reviewed and analyzed, and the risk of complications and/or morbidity or mortality of patient management.
  • **Established Patient Definition**: This code is applicable only for established patients, defined as a patient who has received professional services from the physician or another physician of the exact same specialty and subspecialty in the same group practice within the past three years.
  • **Modifier 25**: When an E/M service (99214) is performed on the same day as a minor procedure (e.g., with a 0 or 10-day global period), it may be reported separately with Modifier 25 (Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service) if the E/M service is distinct and unrelated to the decision to perform the procedure or the procedure itself.
  • **Telehealth Services**: This code can be reported for services delivered via telehealth in accordance with payer-specific policies and regulations.

Associated ICD-10 Codes