A CPT code 99214 is indicated for an “office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making.”
Basically, it’s an important CPT code for evaluation and management (E/M) services – and it’s notoriously undercoded. In fact, a study found that physicians’ code selections were lower than the selections of expert coders in 33 percent of visits with established patients.
That’s a lot of lost revenue.
Now, expert medical coders like us specifically watch for this sort of stuff so that you make as much money as possible, so let’s dive into everything you need to know about CPT code 99214 and how to use it correctly!
Or, hire us and we’ll take it off your plate completely…
Key Points:
- CPT code 99214 is indicated for established patient visits that involve a detailed history, comprehensive examination, and moderate-level medical decision-making.
- You can code 99214 based on time if you spend half of the patient’s visit counseling or coordinating care, and have a total visit time of 30-39 minutes.
- Changes to E/M coding in 2021 put more emphasis on medical decision making and time spent with patients.
- Many physicians lose a lot of revenue because they undercode, make coding mistakes, and miss 99214 coding opportunities.
What Is CPT Code 99214
CPT Code 99214 serves as a critical element within the vast (and often confusing) sea of E/M services outlined in the Current Procedural Terminology (CPT) code set.
We mentioned that code 99214 is indicated for established patient or other outpatient visits that require history, examination, and medical decisions – but did you know that you can code based on the duration of the visit (more on that later)?
Now, the code is not only important for categorizing and communicating the complexity of the patients’ visits, but also influences the reimbursem*nt process for healthcare providers…
Many physicians miss a lot of opportunities to use code 99214 as you saw in the study we mentioned, and that leaves a lot of hard-earned money on the table.
There are generally two options you have for taking care of 99214 coding:
- Juggle your own coding and patients at the same time (we do our best to show you how).
- Hire out your medical billing and give all your attention to your patients, doing what you love.
Overview of the CPT System
The CPT system is overseen by the American Medical Association (AMA), and essentially operates as a standardized language for reporting medical procedures and services.
This set of codes is used across the healthcare spectrum to provide information about the services provided, allowing for accurate medical billing and reporting.
Updates happen periodically, which is important with the evolving medical practices!
Importance of CPT Code 99214 In Medical Billing
There are several reasons as to why CPT code 99214 is so important:
- Accurate Representation: It gives a precise idea of the complexity and duration of established patient encounters, promoting fair and accurate reimbursem*nt for healthcare services.
- Standardized Billing: The use of standardized codes like 99214 streamlines the billing process, lowering errors and ensuring consistency in healthcare practices.
- Reimbursem*nt Determination: Proper use of code 99214 allows healthcare providers to get the appropriate reimbursem*nt from payers, encompassing Medicare and private insurers.
Core Components of CPT Code 99214
There are 3 core components, each contributing to the overall assessment of the patient encounter. To code 99214, 2 of the 3 following used to be required, but there is now a much greater emphasis on medical decision making and time spent with the patient:
1. Detailed Patient History
A detailed history requires that you note:
- Patient’s chief complaint.
- An extended history of the patient’s present illness (4 or more elements).
- Patient’s family or social history directly related to the patient’s illness (could include smoking history, for example).
- A review of 2-9 organ systems.
2. Comprehensive Examination
A proper examination includes closely looking at the affected area or organ system, as well as related body systems, general appearance, vital signs, etc. to provide a comprehensive and thorough understanding of the problem.
3. Medical Decision Making
Changes to E/M coding made in 2021 put more of an emphasis on medical decision making rather than history and physical examination.
In this case, a moderate level of medical decision making is required for code 99214, which is based on 2 of 3 factors:
- The amount of management options being considered for diagnosis/treatment.
- The amount/complexity of data to be reviewed.
- The risks associated with managing or diagnosing the patient.
Using Time For 99214 CPT Code Selection
AMA states that when “using time for code selection, 30-39 minutes of total time is spent on the date of the encounter.”
You also want more than half of the time spent with the patient to involve counseling or coordination of care, which is great because it means that you can code 99214 while ensuring that the level of service is reflective of the time spent with the patient.
So, while that may be another thing to keep track of, it’s also another thing that lets you get more money for your work!
CPT Code 99214 Reimbursem*nt 2024
The current reimbursem*nts for code 99214 at two of the most popular programs are:
- Medicare: $126.07
- Medicaid: $68.97
It’s important to note that some insurance companies only pay 15% over the Medicaid rate in their state, while others pay up to 85% on top of their state’s Medicaid rate. This is obviously a massive range, so it’s important to stay on top of things.
If that sounds like a hassle you don’t want to deal with, feel free to reach out to us and we’ll take care of it!
Level 4 E/M Coding Changes From 2021
2021 saw some revisions to the E/M coding guidelines, which made it quite a bit easier for physicians to code for level 4 services (like those covered by CPT code 99214), but with a bit of a twist…
In those same revisions, they slashed reimbursem*nt for professional practices by 11%!
Basically, you can code more 99214s but your overall profits are likely cut, especially with the problems of undercoding – unless you hire a company like us that’s been in the game for over a decade and knows every trick there is!
The revisions also put more emphasis on the complexity of medical decision-making and total patient time on the day of the encounter, rather than the more rigid requirements for history and physical examination used previously.
If coded right, you have the potential to make more revenue while focusing more on patient care – sounds like a win-win to us!
Comparing Level 4 To Levels 3 & 5
So, when should you code for level 4 instead of levels 3 or 5?
Level 4 visits (CPT code 99214 for established patients and code 99204 for new patients) require a moderate complexity of medical decision making or 30-39 minutes of total physician time on the date of encounter (although you need 45-59 minutes for code 99204).
Level 3 visits require a lower level of medical decision making and less time (typically under 30 minutes). This makes them less complex, and therefore less reimbursable than level 4s.
Level 5 visits are on the other end of the spectrum, requiring a high-complexity of medical decision making or 40+ minutes of patient time for established patients (CPT code 99215) and 60+ minutes for new patients (CPT code 99205).
Accurate coding is obviously super important for getting the proper reimbursem*nt, but many clinicians miss out on those level 4 codes by incorrectly coding for level 3 visits instead, losing out on a ton of money…
Why You Need To Code 99214
The main reason you need to code all the 99214s you possibly can is simple: maximize your revenue.
Although reimbursem*nt has been slashed, it’s easier to code at a higher level, meaning that you’re able to pull in more cash when you do it right…
So, why wouldn’t you code all the 99214s you possibly can?
The truth is – and we’ve heard many physicians say this – coding is time consuming and, well, boring!
You want to spend time with your patients, not figuring out how to get the most amount of money and plowing through paperwork – and we respect that.
However, undercoding is likely making you lose more money than you may have thought…
You lose out on approximately $35 dollars per visit when you undercode for 99214, AKA putting the encounter down as a level 3 instead of a level 4.
That’s a lot of money when you add up the amount of opportunities you have throughout the year to code at this level, and that $35 quickly becomes very important.
There are E/M calculators out there that’ll put a number to your question – how much money you’d lose if you undercode.
Depending on your practice’s volume of patients, you can lose between tens to hundreds of thousands of dollars per year by undercoding…
We get it – you might be scared of over-coding and accidentally shoot yourself in the foot by being too cautious.
That’s exactly why we offer complete coding and billing services that’ll get you the money you deserve – worry-free.
Common Mistakes & Challenges in Reporting Code 99214
It’s obvious that there are many (annoying) challenges when it comes to coding. Some are tougher than others, but all result in less money in your pocket if not taken care of.
- Undercoding: Many healthcare providers undercode despite its importance, leading to revenue loss. This often happens due to incomplete documentation or concerns of fraud and abuse.
- Coding Complexity: E/M documentation guidelines aren’t the most straightforward, and cause mistakes and challenges when trying to accurately report code 99214.
- CPT Coding Changes: Without continually keeping up-to-date with the constantly updating CPT coding system, it can be difficult to ensure compliance.
A lot of these mistakes and challenges can be avoided by using revenue cycle management best practices, which is what many clinics choose to outsource so they can focus on the patient-care side of things.
Conclusion
While CPT code 99214 is super important in healthcare billing, it’s not always easy to understand exactly what it is, how to use it, when to use it, and why to use it.
Educating yourself and continually watching the revisions and updates of CPT codes will help you navigate the complexities of medical coding, and allow you to provide high-quality patient care while receiving fair reimbursem*nt.
That said, you may want to focus on your patients, not this stuff. In that case, we here at The Auctus Group are there for you, offering our comprehensive services that’ll take care of your billing and coding needs!
Give us a shout and we’ll get your coding sorted – and get you paid!
FAQs
What is the difference between codes 99213 and 99214?
CPT code 99213 is for brief encounters with established patients involving limited history, examination, and straightforward decision-making (15-29 minutes). Code 99214 indicates a comprehensive encounter with detailed history, examination, and moderate complexity medical decision-making (30-39 minutes).
What level of care is 99214?
CPT defines a code 99214 as a level-4 of care.
Does 99214 need a modifier?
Modifiers can be used with 99214 if applicable. For example, you can add Modifier 25 to the E/M visit with 99214 if there was a “separately identifiable E/M on the same day of a procedure” (source: ACC). Or add modifier 22 if the procedure was extra complex.
Are CPT codes part of ICD-9 or ICD-10?
CPT and ICD codes are similar, but CPT codes describe a procedure while ICD codes describe a diagnosis or issue.
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