What constitutes a 99214 (Current Procedural Terminology) code?

What Constitutes a 99214 CPT Code

A 99214 CPT code requires moderate complexity medical decision making, along with a detailed history and examination, or alternatively can be billed based on 25 minutes of total time spent with an established patient. 1

Key Components for 99214 Coding

For established patients, only two of the three key components need to meet or exceed the specified level:

1. Medical Decision Making (Moderate Complexity):

   • Management of multiple chronic conditions
   • Moderate risk of morbidity
   • Acute illness with systemic symptoms
   • Undiagnosed new problems with uncertain prognosis
   • Acute injuries requiring detailed evaluation

2. History (Detailed):

   • Chief complaint
   • Extended history of present illness (4+ elements)
   • Problem-pertinent review of systems
   • Pertinent past, family, and/or social history

3. Examination (Detailed):

   • Extended examination of affected body area(s) and other symptomatic or related organ system(s)
   • Documentation of findings in multiple systems

Time-Based Coding Alternative

If using time as the determining factor:

• 99214 typically requires 25 minutes of face-to-face time when more than 50% is spent counseling or coordinating care 1
• Under the 2021 guidelines, total time (including non-face-to-face work) can be used instead of the key components

Common Pitfalls and Caveats

1. Undercoding: Research shows significant undercoding in resident clinics, with 72.1% of visits coded at 99213 or lower that could have qualified as 99214 or higher 2

2. Documentation Requirements:

   • Must clearly document the elements supporting moderate complexity
   • When using time, document total time spent and specify counseling/coordination activities
   • Avoid insufficient documentation that doesn't support the level billed

3. Telehealth Considerations:

   • Video visits may have different complexity patterns compared to in-person visits
   • In some specialties like primary care, video visits tend to be coded at lower complexity levels than in-person visits 3

4. Modifier Usage:

   • When billing 99214 with a preventive service on the same day, use modifier -25 to indicate a significant, separately identifiable E/M service
   • Separate documentation for preventive and problem-oriented components is required 1

Coding Algorithm

1. Assess medical decision making complexity:

   • If moderate complexity (multiple diagnoses, moderate data review, moderate risk) → Consider 99214
   • If low complexity → Consider 99213
   • If high complexity → Consider 99215

2. Evaluate history and examination detail:

   • For 99214, need detailed history AND/OR detailed examination

3. Calculate time spent:

   • If total time ≥ 25 minutes → Can qualify for 99214 based on time alone
   • Document time spent if using this method

4. Review documentation:

   • Ensure documentation supports the code level selected
   • Verify medical necessity is clearly established

By following these guidelines and ensuring proper documentation, providers can accurately bill 99214 codes when appropriate, avoiding both undercoding (which leads to lost revenue) and overcoding (which can trigger audits).