What are the billing requirements for an established level 4 (Current Procedural Terminology - CPT) visit?

Requirements for Billing an Established Level 4 Visit

For an established patient level 4 visit (CPT code 99214), documentation must demonstrate either moderate medical decision-making complexity or a total time of at least 25 minutes with more than half spent counseling the patient. 1, 2

Medical Decision-Making Requirements

To qualify for a level 4 established patient visit based on medical decision-making complexity, the documentation must demonstrate:

• Moderate complexity medical decision-making that includes at least two of these three elements 1:
  • Moderate number of diagnoses or management options
  • Moderate amount of data to review
  • Moderate risk of complications, morbidity, or mortality

Time-Based Requirements

Alternatively, the visit can qualify as level 4 based on time:

• Total face-to-face time of at least 25 minutes with more than half spent counseling the patient 1, 2
• For telehealth visits, the total time must be documented in the visit note 1

Documentation Requirements

The following elements should be documented to support a level 4 established patient visit:

• Detailed interval history 1
• Detailed examination (though the 2021 coding changes eliminated the requirement to document physical examination findings to support coding levels) 1, 3
• Moderate complexity medical decision-making 1
• For telehealth visits, additional documentation requirements include 1:
  • Patient consent to telemedicine
  • Method of telemedicine (secure 2-way interactive video or phone)
  • Patient location
  • Provider location
  • Clinical participants' roles and actions
  • Other individuals present at the visit

Common Pitfalls and How to Avoid Them

• Underbilling: Studies show that 55% of resident encounters are underbilled by an average of $45.26 per encounter 2

  • Junior residents tend to underbill more frequently than senior residents (74.2% for PGY-1 vs. 42.9% for PGY-3) 2
  • Solution: Use standardized documentation forms and receive proper training on billing requirements 4

• Overbilling: About 18% of encounters are overbilled by an average of $51.29 per encounter 2

  • Documentation errors can lead to inflated billing levels not justified by the actual care provided 5
  • Solution: Ensure documentation accurately reflects the care delivered and meets the specific requirements for the billed level 5

• Documentation discrepancies: Studies found 90% of notes contained at least one error when compared to audio recordings of the actual visit 5

  • Solution: Focus on accurate documentation that reflects the actual care provided rather than template-driven documentation 5

Recent Changes to E&M Guidelines

• In 2021, the American Medical Association updated guidance for outpatient E&M visit codes 3
• These changes:
  • Account for provider time outside of face-to-face encounters 3
  • Reduce documentation requirements 3
  • Eliminated the requirement to document physical examination findings to support coding levels 1
  • Led to a 2.2% relative increase in level 4 visits and a 22.6% relative increase in level 5 visits 3

Billing Tips

• Use appropriate CPT codes (99214 for established level 4 patients) 1
• For telehealth visits, include the appropriate Place of Service code and telehealth CPT modifier (e.g., 95, GQ, or GT) based on payer specifications 1
• Consider using standardized history and physical examination forms, which have been shown to increase appropriate billing levels and billable income 4
• Ensure proper documentation of time spent if billing based on time rather than complexity 1