99214

Office or Outpatient Evaluation and Management of an Established Patient, Moderate Complexity

CPT 99214 is an evaluation and management (E&M) code for an established patient in an office or other outpatient setting. This code requires a moderate level of medical decision making (MDM) or a total time of 30-39 minutes spent on the date of the encounter. An established patient is defined as one who has received professional services from the physician or another physician of the same specialty and subspecialty within the same group practice within the past three years. Since the 2021 guideline revisions, the level of service is determined solely by MDM or time, removing the rigid requirements for specific elements of history and physical examination, though a medically appropriate history and/or exam must still be documented. For the MDM component, moderate complexity typically involves addressing two or more stable chronic illnesses, one chronic illness with exacerbation or progression, or one undiagnosed new problem with an uncertain prognosis. Data requirements for this level include the review of prior records, ordering unique tests, or interpreting external results. The risk of complications is often characterized by prescription drug management or decisions regarding minor surgery with identified patient risk factors. When coding by time, the clinician must account for all activities performed on the day of the encounter, including pre-visit preparation, face-to-face time, and post-visit documentation or care coordination. Documentation must clearly support that the complexity of the patient's condition or the time spent justifies the moderate-level reimbursement rate to ensure compliance and avoid audit risks.

Clinical Indications

  • Management of two or more stable chronic conditions such as hypertension and type 2 diabetes.
  • Evaluation of a chronic condition showing signs of progression or side effects from therapy.
  • Assessment of a new undiagnosed problem with an uncertain prognosis (e.g., a breast lump or unexplained weight loss).
  • Management of an acute illness with systemic symptoms (e.g., pyelonephritis or pneumonia).
  • Refining a treatment plan that involves prescription drug management.
  • Follow-up for a patient recovering from a major surgery or hospitalization requiring moderate oversight.

Procedure Steps

  1. Review of the patient's medical record, previous lab results, and imaging prior to the encounter.
  2. Performance of a medically appropriate history, including Chief Complaint (CC) and History of Present Illness (HPI).
  3. Performance of a medically appropriate physical examination based on the patient's presenting symptoms.
  4. Assessment of the patient's condition(s) using the Three Elements of Medical Decision Making: Number/Complexity of Problems, Data Review, and Risk.
  5. Discussion of diagnostic and treatment options with the patient or representative.
  6. Ordering of necessary laboratory tests, imaging, or referrals to specialists.
  7. Prescription drug management, including starting new medications or adjusting existing dosages.
  8. Documentation of the total time spent (if coding by time) or the clinical logic behind the MDM level.

Coding Guidelines

  • Used only for established patients in outpatient settings.
  • Level selected based on either Medical Decision Making (MDM) or total time spent on the date of the encounter.
  • Total time for 99214 is 30 to 39 minutes.
  • History and Physical Exam must be 'medically appropriate' but do not determine the code level.
  • Prescription drug management is a common indicator of 'Moderate Risk' for MDM calculation.
  • If a procedure is performed on the same day, append Modifier 25 to the E&M code if it is a significant, separately identifiable service.
  • Do not count time spent on procedures that have their own CPT codes.
  • Cannot be billed if the patient has been seen by the same specialty/group within 3 years (use New Patient codes instead).

Associated ICD-10 Codes