Should I use code 99213 or 99214 for an established patient office visit?

Selecting Between 99213 and 99214 for Established Patient Office Visits

For established patient office visits, code 99214 should be used when the visit involves moderate complexity medical decision making and meets at least two of the three key components (history, examination, and medical decision-making) at the detailed level. 1

Key Components for Code Selection

For established patients, only two of the three key components need to meet or exceed the specified level to qualify for a particular code:

99213 Requirements:

• Expanded problem-focused history
• Expanded problem-focused examination
• Low complexity medical decision making
• Typically 15 minutes face-to-face time

99214 Requirements:

• Detailed history
• Detailed examination
• Moderate complexity medical decision making
• Typically 25 minutes face-to-face time when >50% is spent counseling 1

Medical Decision Making Criteria

Medical decision making is often the most important factor in determining the appropriate code. Use 99214 when the visit involves:

• Multiple chronic conditions requiring management
• Moderate risk of morbidity
• Acute illness with systemic symptoms
• Undiagnosed new problems with uncertain prognosis
• Acute injuries requiring detailed assessment 1

Documentation Requirements

When coding 99214, ensure your documentation clearly demonstrates:

• Detailed history and/or examination
• Moderate complexity medical decision making
• Medical necessity for all services provided
• Time spent if using time as the determining factor 1

Common Pitfalls to Avoid

1. Undercoding: Research shows significant undercoding in physician practices, particularly in residency settings where 72.1% of visits coded as 99213 or lower could have been coded as 99214 or higher 2

2. Insufficient documentation: Ensure documentation supports the level of service billed

3. Incorrect modifier usage: When billing both preventive and problem-oriented services on the same day, use modifier 25 appropriately 1

4. Overlooking time-based coding: When counseling or coordination of care dominates the visit (>50% of time), time can be the controlling factor for code selection 1

Decision Algorithm

1. Assess complexity of medical decision making:

   • Low complexity → Consider 99213
   • Moderate complexity → Consider 99214

2. Evaluate other key components:

   • If at least one other component (history or exam) meets the detailed level → 99214
   • If both history and exam are only expanded problem-focused → 99213

3. Consider time spent:

   • If face-to-face time is approximately 25 minutes with >50% spent counseling → 99214
   • If face-to-face time is approximately 15 minutes → 99213

By following these guidelines and ensuring proper documentation, you can accurately select between 99213 and 99214 codes while avoiding both undercoding and overcoding.