Is a patient visit for review of thyroid ultrasound (US) results, referral for fine-needle aspiration (FNA), and thyroid function tests (TFTs) due to sleep disturbances billable as 99214?

CPT 99214 Billing for Thyroid Evaluation Visit

This visit is billable as CPT 99214 if the medical decision-making (MDM) complexity meets moderate level criteria, which is likely satisfied by ordering and interpreting thyroid ultrasound, reviewing thyroid function tests, and arranging referral for fine-needle aspiration biopsy.

Medical Decision-Making Complexity Assessment

The CPT 99214 code requires moderate complexity MDM, defined by at least two of three elements: moderate number/complexity of problems addressed, moderate amount/complexity of data reviewed and analyzed, or moderate risk of complications/morbidity/mortality 1.

Problems Addressed

• Sleep disturbances as the presenting complaint represent a moderate-complexity problem when thyroid pathology is being investigated, as thyroid dysfunction commonly causes sleep disruption 2
• The discovery of thyroid nodules requiring FNA evaluation elevates this to a chronic illness with exacerbation, which qualifies as moderate complexity 1

Data Reviewed and Analyzed

• Reviewing thyroid ultrasound results constitutes independent interpretation of tests, particularly when assessing for suspicious features such as solid composition, hypoechogenicity, microcalcifications, irregular margins, or absence of peripheral halo 1, 3
• Interpreting thyroid function tests (TSH, T3, T4) adds to data complexity, as higher TSH levels associate with increased malignancy risk in thyroid nodules 4
• Ordering ultrasound-guided FNA represents ordering and managing a Category 1 test (pathology), which contributes to moderate data complexity 1, 5

Risk of Complications

• Referral for FNA biopsy involves moderate risk, as this is an invasive diagnostic procedure with potential complications including perilesional hematomas and vasovagal episodes (1.1% complication rate) 6
• The differential diagnosis includes thyroid malignancy, which carries significant morbidity if not properly evaluated—papillary thyroid carcinoma accounts for 80% of thyroid cancers with a 10-year survival of 93% when appropriately managed 2

Documentation Requirements for 99214

To support this billing level, your documentation must clearly demonstrate:

• Chief complaint and history: Document sleep disturbances as the presenting symptom and any associated thyroid-related symptoms (fatigue, weight changes, palpitations, heat/cold intolerance) 2
• Review of thyroid ultrasound: Specifically note nodule size, echogenicity, presence/absence of microcalcifications, margin characteristics, and vascularity pattern—these features determine FNA indication 1, 4
• Interpretation of TFTs: Document TSH level and its clinical significance, as elevated TSH increases malignancy risk 4
• Clinical reasoning for FNA referral: State why FNA is indicated based on nodule characteristics—guidelines recommend FNA for nodules >1 cm with suspicious features or any nodule >4 cm regardless of appearance 1, 4
• Patient counseling: Document discussion of FNA procedure, malignancy risk stratification, and management plan based on potential cytology results (Bethesda classification) 1, 5

Common Pitfalls to Avoid

• Insufficient documentation of medical necessity: Simply stating "reviewed ultrasound" without describing specific findings and their clinical significance may not support moderate complexity MDM 1
• Failure to link sleep disturbances to thyroid evaluation: Document the clinical reasoning connecting the presenting complaint to thyroid pathology—both hyperthyroidism and hypothyroidism cause sleep disruption 2
• Not documenting risk discussion: The moderate risk level requires documentation of counseling about FNA complications and potential surgical intervention if malignancy is confirmed 6, 5
• Inadequate time documentation if using time-based billing: If billing based on total time (40-54 minutes for 99214), document all time spent on the date of encounter including review of records, examination, counseling, and care coordination 1

Clinical Context Supporting Billing Level

• FNA is the gold standard for preoperative thyroid nodule diagnosis, with 81-82% adequacy rates when performed with ultrasound guidance 5, 7
• Ultrasound-guided FNA is superior to palpation-guided biopsy in accuracy, patient comfort, and cost-effectiveness, justifying the complexity of arranging this specific procedure 1, 8
• Thyroid cancer incidence is increasing 6.2% annually and represents the sixth most common malignancy in women, making appropriate evaluation medically necessary 2
• Sleep disturbances are a legitimate presenting complaint for thyroid evaluation, as both hyper- and hypothyroidism disrupt sleep architecture through multiple mechanisms including nocturnal dyspnea, palpitations, and altered sleep-wake cycles 2