99214

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

Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When time is used to select the level of service, 30-39 minutes of total time is spent on the date of the encounter. This level of service is characterized by addressing problems that are often complex or involve multiple stable chronic illnesses, new problems requiring a limited workup, or the management of one chronic illness with mild exacerbation.

Clinical Indications

  • Management of a patient with multiple chronic conditions (e.g., diabetes, hypertension, hyperlipidemia) requiring medication adjustments and lifestyle counseling.
  • Evaluation of a new problem of moderate severity (e.g., sudden onset of severe abdominal pain with stable vitals, requiring diagnostic workup).
  • Follow-up for a patient post-hospital discharge requiring detailed review of hospital records, medication reconciliation, and formulation of a new care plan.
  • Management of a chronic condition with an exacerbation (e.g., asthma exacerbation requiring assessment, potential nebulizer treatment, and adjustment of maintenance therapy).
  • Pre-operative clearance for a patient with multiple comorbidities requiring thorough risk assessment and optimization.
  • Detailed evaluation for a new concern that impacts multiple organ systems or has a broad differential diagnosis.

Procedure Steps

  1. Perform a medically appropriate interval history, focusing on the chief complaint, relevant review of systems, and pertinent past medical, family, and social history updates.
  2. Conduct a medically appropriate physical examination, which may be problem-focused or expanded problem-focused, targeting relevant organ systems.
  3. Formulate an assessment and plan, involving: review and/or ordering of diagnostic tests (e.g., laboratory studies, imaging) to assess disease progression, new symptoms, or potential complications.
  4. Evaluate and discuss multiple treatment options, which may include initiation or adjustment of medications, referrals to specialists, and/or lifestyle modifications.
  5. Consider the patient's prognosis, risks, and benefits of management options, including discussion of potential adverse outcomes.
  6. Provide comprehensive patient education and counseling on disease management, prevention strategies, and required follow-up care.
  7. Coordinate care with other healthcare professionals or specialists, as needed.
  8. Document the encounter comprehensively, ensuring that the history, examination, medical decision making, or total time spent clearly support the reported level of service.

Coding Guidelines

  • The level of E/M service for 99214 is determined by either the level of Medical Decision Making (MDM) or total time spent on the date of the encounter. For 99214, MDM must be at a Moderate level.
  • Moderate MDM requires meeting at least two of the three MDM elements: moderate number and complexity of problems addressed, moderate amount and/or complexity of data to be reviewed and analyzed, and moderate risk of complications and/or morbidity or mortality of patient management.
  • If using time, 30-39 minutes of total time must be documented. Total time includes both face-to-face and non-face-to-face time personally spent by the physician or other qualified healthcare professional (QHP) on the date of the encounter.
  • Examples of activities included in total time: preparing to see the patient; obtaining and/or reviewing history; performing a medically appropriate examination; counseling and educating the patient/family; ordering medications, tests, or procedures; referring and communicating with other healthcare professionals; documenting the clinical encounter.
  • Do not report 99214 for services where the primary reason for the encounter is not evaluation and management (e.g., only immunization administration, only venipuncture).
  • When a significant, separately identifiable E/M service is performed on the same day as a minor procedure, modifier 25 may be appended to 99214 to indicate that the E/M service was significant and separately identifiable from the procedure.

Associated ICD-10 Codes