What is the MDM (Medical Decision-Making) CPT (Current Procedural Terminology) code for a moderately complex office visit with an established patient?

MDM CPT Code for This Visit: 99214

Based on the visit documentation, the appropriate CPT code is 99214 (established patient office visit with moderate complexity medical decision-making). 1, 2

Time-Based Analysis

The documented visit time was 15 minutes and 26 seconds (11:38:28 - 11:53:54), which falls short of the 30-39 minute threshold required for 99214 coding based on time alone. 1, 2 Therefore, time-based coding cannot support 99214 for this encounter. 2

Medical Decision-Making (MDM) Complexity Assessment

The visit qualifies for 99214 based on moderate complexity MDM, which requires meeting 2 out of 3 elements: number/complexity of problems, amount/complexity of data, and risk of complications. 1, 2

Problems Addressed (Moderate Complexity - Met)

• Multiple chronic conditions with exacerbation: Autism spectrum disorder with associated feeding disorder, pervasive developmental delay with potty training regression, and visual food rejection represent undiagnosed new problems with uncertain prognosis regarding treatment response. 1
• The feeding difficulties requiring multiple specialist referrals (OT, SLP, nutrition) and the behavioral regression constitute problems that were actively addressed during the encounter, not merely listed. 2

Amount/Complexity of Data (Moderate Complexity - Met)

• Review of previous medical records from the provider's office was documented. 3
• Coordination of care involving reissuing multiple referrals (occupational therapy to different facility, speech therapy to new provider joining practice, nutrition consultation follow-up) demonstrates data complexity. 3
• The provider arranged for referral processing with contact information changes due to parental work schedules, indicating care coordination complexity. 1

Risk of Complications (Low to Moderate)

• No medications were prescribed or adjusted, which limits the risk category. 3
• However, the chronic nature of autism-related feeding difficulties with nutritional implications and developmental regression represents ongoing management of chronic illness. 1

MDM Level Determination

Since 2 out of 3 MDM elements (Problems and Data) clearly meet moderate complexity criteria, the overall MDM qualifies as moderate complexity, supporting 99214. 1, 2

Critical Coding Considerations

• This is an established patient visit (follow-up visit documented), so only 2 of 3 key components need to be met for code selection. 3, 4
• The 2021 CPT guidelines allow billing based on either total time OR medical decision-making complexity, whichever is supported by documentation. 1, 2
• Common pitfall avoided: The outdated 2013 guideline suggesting 25 minutes for 99214 does not apply; current guidelines require 30-39 minutes for time-based coding. 3, 2

Documentation Supports 99214

The encounter activities listed in the billing section explicitly document:

• Preparing to see patient (review of records) 3
• Obtaining current status 3
• Performing medically appropriate evaluation 3
• Counseling and educating the father 3
• Coordinating multiple referrals (OT, SLP, nutrition) 3, 1
• Referring and communicating with therapy providers for wraparound services 3
• Care coordination for multiple therapeutic interventions 3, 1

These documented activities support moderate complexity MDM even without meeting the time threshold, making 99214 the appropriate code. 1, 2