99214

Office or other outpatient visit for the evaluation and management of an established patient, moderate level of medical decision making

CPT code 99214 is utilized for the evaluation and management (E/M) of an established patient in an office or other outpatient setting. An established patient is defined as one who has received professional services from the physician or another physician of the same specialty and subspecialty in the same group practice within the previous three years. Per the current CPT guidelines, the selection of this code level is determined by either the level of medical decision making (MDM) or the total time spent on the date of the encounter. When using MDM, 99214 requires a moderate level of complexity. Moderate MDM is characterized by meeting at least two of the following three components: 1) Moderate number and complexity of problems addressed, such as one or more chronic illnesses with exacerbation, progression, or side effects of treatment, or two or more stable chronic illnesses; 2) Moderate amount and/or complexity of data to be reviewed and analyzed, which may include reviewing prior external notes, interpreting tests performed by another provider, or using an independent historian; and 3) Moderate risk of complications and/or morbidity or mortality of patient management, commonly exemplified by prescription drug management or decisions regarding minor surgery with identified patient or procedure risk factors. Alternatively, if time is used for code selection, 99214 requires a total time of 30-39 minutes spent on the date of the encounter. This total time includes both face-to-face and non-face-to-face work performed by the provider, such as reviewing records before the visit, the actual examination, and documenting the encounter or coordinating care after the patient leaves.

Clinical Indications

  • Follow-up for two or more stable chronic conditions such as hypertension and type 2 diabetes.
  • Evaluation of a chronic condition showing signs of exacerbation or progression.
  • Management of an acute illness with systemic symptoms (e.g., pyelonephritis or pneumonia).
  • Management of an undiagnosed new problem with an uncertain prognosis.
  • Review and adjustment of prescription medications requiring moderate monitoring.
  • Follow-up for a patient with a stable condition requiring significant data review from external specialists.

Procedure Steps

  1. Review of the patient's medical record and previous encounter notes prior to the visit.
  2. Performance of a medically appropriate history and physical examination, though these do not determine the code level.
  3. Assessment of the patient's presenting problems, focusing on the status of chronic or acute conditions.
  4. Review and interpretation of laboratory results, imaging, or other diagnostic tests.
  5. Development of a management plan, which may include ordering new tests, referring to specialists, or prescribing medications.
  6. Counseling and educating the patient or caregiver regarding the diagnosis and treatment plan.
  7. Documentation of the total time spent (if coding by time) or the specific elements of MDM (if coding by complexity).

Coding Guidelines

  • Code 99214 requires a moderate level of medical decision making (MDM).
  • If billing by time, the provider must spend 30-39 minutes of total time on the date of the encounter.
  • Do not count time spent by clinical staff; only the time of the physician or qualified healthcare professional is counted.
  • Prescription drug management is a common indicator of moderate risk, but the documentation must show active management or decision-making regarding the drug.
  • History and exam must be performed as medically appropriate, but their extent does not influence the code selection.
  • If the patient is 'new' (not seen in 3 years), use code 99204 for a similar level of complexity.
  • For encounters exceeding 54 minutes, consider using prolonged service codes (e.g., G2212 for Medicare) if applicable.

Associated ICD-10 Codes