Medicare Cost for CPT Code 99214
The Medicare cost for a 99214 office visit varies by geographic location but generally ranges from $90 to $110, with the national average being approximately $100.
Understanding CPT Code 99214
CPT code 99214 is used for established patient office visits with moderate complexity medical decision making or visits that typically require 25-39 minutes of face-to-face time with the physician. This code is part of the Evaluation and Management (E/M) services and is commonly used in outpatient settings.
Medicare Reimbursement Structure
Medicare reimbursement for CPT code 99214 follows these principles:
- Payments are based on the Resource-Based Relative Value Scale (RBVS) system
- The total payment consists of three components:
- Physician work (time and effort)
- Practice expense (overhead costs)
- Malpractice expense
Factors Affecting Reimbursement
Several factors influence the exact reimbursement amount:
- Geographic location: Significant variations exist based on regional cost differences
- Setting of care: Office-based vs. facility-based services
- Medicare Administrative Contractor (MAC): Different MACs may have slight variations in payment rates
- Modifiers: Use of certain modifiers may affect payment
Telehealth Considerations
When 99214 is billed for telehealth services:
- The same CPT code is used with appropriate telehealth modifiers (e.g., modifier 95)
- Place of Service code must reflect telehealth delivery
- For audiovisual encounters, billing is based on complexity (same as in-person)
- For telephone-only visits, billing is based on time 1
- The total relative value unit (RVU) for a virtual visit would be approximately 1.62 compared to 2.09 for an in-office visit 2
Common Billing Pitfalls
- Undercoding: Research shows significant undercoding in residency settings, with 72.1% of visits coded at 99213 or lower that could have been coded as 99214 or higher 3
- Documentation requirements: Ensure documentation supports the level of service billed
- Modifier usage: Incorrect use of modifiers can lead to claim denials
Medicare Advantage vs. Traditional Medicare
For physicians considering Medicare Advantage plans:
- MA plans typically pay physicians approximately 96.9% of traditional Medicare rates for common office visits 4
- For a 99214 visit, this would mean a slightly lower reimbursement compared to traditional Medicare
Understanding the Medicare reimbursement for 99214 is essential for proper medical billing and practice revenue management. Physicians should ensure their documentation supports the level of service provided to avoid potential undercoding that could impact practice revenue.