{"id":10599,"date":"2020-02-26T18:00:36","date_gmt":"2020-02-26T12:30:36","guid":{"rendered":"https:\/\/www.medicalbillersandcoders.com\/blog\/?p=10599"},"modified":"2026-06-02T08:52:13","modified_gmt":"2026-06-02T03:22:13","slug":"how-to-use-cpt-code-99214-correctly","status":"publish","type":"post","link":"https:\/\/www.medicalbillersandcoders.com\/blog\/how-to-use-cpt-code-99214-correctly\/","title":{"rendered":"How to use CPT CODE 99214 Correctly?"},"content":{"rendered":"<p><strong data-start=\"0\" data-end=\"18\">CPT Code 99214<\/strong> is commonly used for billing office or outpatient visits involving established patients with moderate to high complexity in medical decision-making. To meet the criteria for this level of Evaluation and Management (E\/M) service, proper documentation is critical.<\/p>\r\n<p>It requires a detailed history, detailed examination, and medical decision-making of moderate to high complexity. Failing to document these requirements accurately can result in claim denials or revenue loss. That\u2019s why partnering with experienced <a class=\"cursor-pointer\" href=\"https:\/\/www.medicalbillersandcoders.com\/\" rel=\"noopener\" data-start=\"751\" data-end=\"834\">Evaluation and Management billing experts<\/a> is essential for accurate code selection and optimal reimbursement.<\/p>\r\n<p style=\"text-align: left;\">Medicare allows only the medically necessary portion of the visit. Even if a complete note is generated, only the necessary services for the condition of the patient at the time of the visit can be considered in determining the level of an E\/M code. A chronological description of the development of the patient\u2019s present illness from the first sign and\/or symptom or from the previous encounter to the present.<\/p>\r\n<p style=\"text-align: left;\">Descriptions of present illness may include Location; Quality; Severity; Timing; Context; Modifying factors; and Associated signs\/symptoms significantly related to the presenting problem(s).\u00a0The Chief Complaint is a concise statement from the patient describing the symptom; Problem; Condition; Diagnosis; and Physician recommended return or other factors that are the reason for the encounter.<\/p>\r\n<p style=\"text-align: left;\">An inventory of body systems is obtained through a series of questions seeking to identify signs and\/or symptoms that the patient may be experiencing or has experienced. For purpose of Review of Systems these systems are recognized as Constitutional (i.e., fever, weight loss); Eyes; Ears, Nose, Mouth Throat; Cardiovascular; Respiratory; Gastrointestinal; Genitourinary; Musculoskeletal; Integumentary (skin and\/or breast); Neurologic; Psychiatric; Endocrine; Hematologic\/Lymphatic; and Allergic\/Immunologic.<\/p>\r\n<h2 style=\"text-align: left;\">Detailed Physical Exam Includes:<\/h2>\r\n<ul style=\"text-align: left;\">\r\n<li style=\"text-align: justify;\">Extended exam of the affected body region or organ system: For the purposes of examination these body areas are recognized &#8211; Head, including the face; Neck; Chest, including breasts and axillae; Abdomen; Genitalia, groin, buttocks; Back, including spine; and Each extremity<\/li>\r\n<li style=\"text-align: justify;\">Symptomatic\/related body systems or organ systems: For the purposes of examination these organ systems are recognized &#8211; Constitutional (i.e., vital signs, general appearance); Eyes; Ears, nose, mouth, and throat; Cardiovascular; Respiratory; Gastrointestinal; Genitourinary; Musculoskeletal; Skin; Neurologic; Psychiatric; and Hematologic\/lymphatic\/immunologic<\/li>\r\n<\/ul>\r\n<h3 style=\"text-align: left;\">Past, Family, And\/or Social History (PFSH) Consists of a review of the following:<\/h3>\r\n<ul style=\"text-align: left;\">\r\n<li style=\"text-align: left;\">Past history (the patient\u2019s past experiences with illnesses, operations, injuries, and treatments)<\/li>\r\n<li style=\"text-align: left;\">Family history (a review of medical events in the patient\u2019s family, including diseases which may be hereditary or place the patient at risk)<\/li>\r\n<li style=\"text-align: left;\">Social History (an age-appropriate review of past and current activities)<\/li>\r\n<\/ul>\r\n<h3 style=\"text-align: left;\">Detailed History:<\/h3>\r\n<ul style=\"text-align: left;\">\r\n<li style=\"text-align: left;\">Chief complaint<\/li>\r\n<li style=\"text-align: left;\">An extended history of present illness<\/li>\r\n<li style=\"text-align: left;\">Extended review of systems<\/li>\r\n<li style=\"text-align: left;\">Pertinent past family\/ social history DIRECTLY related to the patient\u2019s problems<\/li>\r\n<\/ul>\r\n<h3 style=\"text-align: left;\">Medical Decision Making of HIGH complexity involves 2 of the 3 below:<\/h3>\r\n<ul style=\"text-align: left;\">\r\n<li style=\"text-align: left;\">Extensive management options for diagnosis or treatment<\/li>\r\n<li style=\"text-align: left;\">An extensive amount of data to be reviewed<\/li>\r\n<li style=\"text-align: left;\">High risk of complications and\/or morbidity or mortality<\/li>\r\n<\/ul>\r\n<h3 style=\"text-align: left;\">A moderate amount of data to be reviewed consists of:<\/h3>\r\n<ul style=\"text-align: left;\">\r\n<li style=\"text-align: left;\">Lab results<\/li>\r\n<li style=\"text-align: left;\">Diagnostic &amp; imaging results<\/li>\r\n<li style=\"text-align: left;\">Other practitioners\u2019 notes\/ charts (e.g., PT, OT, consulting physicians)<\/li>\r\n<li style=\"text-align: left;\">Labs or diagnostics that need to be performed<\/li>\r\n<\/ul>\r\n<h3 style=\"text-align: left;\">Moderate risk of complications and\/or morbidity or mortality:<\/h3>\r\n<ul style=\"text-align: left;\">\r\n<li style=\"text-align: left;\">Comorbidities associated with the presenting problem<\/li>\r\n<li style=\"text-align: left;\">Risk(s) of diagnostic procedures(s) performed<\/li>\r\n<li style=\"text-align: left;\">Risk(s) associated with possible management options<\/li>\r\n<\/ul>\r\n<h3 style=\"text-align: left;\">Additional Information:<\/h3>\r\n<ul style=\"text-align: left;\">\r\n<li><strong>Select the code for the service based upon the content of the service:<\/strong>\r\n<ul>\r\n<li>Duration of the visit does NOT control the level of the service to be billed unless more than 50% of the face-to-face time (for non-inpatient service) or more than 50% of the floor time (for inpatient service) is spent providing counseling or coordination of care as described in CMS Publication 100-04 (link provided in the reference section of this Fact Sheet)<\/li>\r\n<\/ul>\r\n<\/li>\r\n<li><strong>Practitioner\u2019s choosing to use time as the determining factor:<\/strong>\r\n<ul>\r\n<li>MUST document time in the patient\u2019s medical record.<\/li>\r\n<li>The documentation MUST support in sufficient detail the nature of the counseling<\/li>\r\n<\/ul>\r\n<\/li>\r\n<li>Code selection based on the total time of the face-to-face encounter (floor time), the medical record MUST be documented in sufficient detail to justify the code selection<\/li>\r\n<li>Face-to-face time refers to the time with the physician ONLY. Counseling by other staff is not considered to be part of the face-to-face physician\/patient encounter time. Therefore, the time spent by other staff is NOT considered in selecting the appropriate level of service<\/li>\r\n<li>Comorbidities and other underlying diseases in and of themselves are not considered when selecting the E\/M codes UNLESS their presence significantly increases the complexity of the medical decision making<\/li>\r\n<li>Please note that ALL services ordered or rendered to Medicare beneficiaries MUST be signed. Signatures may be handwritten or electronically signed; exceptions for stamped signatures. You should NOT add late signatures to a medical record but instead, make use of the signature authentication process<\/li>\r\n<\/ul>\r\n<p style=\"text-align: left;\">To get reimbursed properly, you need <a href=\"https:\/\/www.medicalbillersandcoders.com\/medical-billing-services.aspx\">medical billing and coding experts<\/a> who are aware of all these details along with documentation requirements or simply you can connect with <strong>Medical Billers and Coders (MBC)<\/strong>.<\/p>\r\n<p style=\"text-align: left;\">Our billers and coders have great experience which reduces your billing worries and you can focus only on patient care. To know more about our billing and coding services you can contact us at <a href=\"tel:888-357-3226\"><strong>888-357-3226<\/strong><\/a>\/ <a href=\"mailto:info@medicalbillersandcoders.com\">info@medicalbillersandcoders.com<\/a><\/p>\r\n<h2 style=\"text-align: left;\"><strong>FAQs:<\/strong><\/h2>\r\n\r\n<div class=\"schema-faq wp-block-yoast-faq-block\">\r\n<div id=\"faq-question-1746010654027\" class=\"schema-faq-section\"><strong class=\"schema-faq-question\">1. What determines the level of an E\/M code under Medicare?<\/strong>\r\n<p class=\"schema-faq-answer\">The level is based on the medically necessary services for the patient&#8217;s condition, not the overall length of the visit.<\/p>\r\n<\/div>\r\n<div id=\"faq-question-1746010670398\" class=\"schema-faq-section\"><strong class=\"schema-faq-question\">2. How should the History of Present Illness (HPI) be documented?<\/strong>\r\n<p class=\"schema-faq-answer\">Document a detailed timeline of the patient\u2019s illness, including symptoms, severity, and timing.<\/p>\r\n<\/div>\r\n<div id=\"faq-question-1746010679888\" class=\"schema-faq-section\"><strong class=\"schema-faq-question\">3. What is included in a Detailed Physical Exam?<\/strong>\r\n<p class=\"schema-faq-answer\">It involves a thorough exam of affected body areas and related organ systems, such as the chest and cardiovascular system.<\/p>\r\n<\/div>\r\n<div id=\"faq-question-1746010688483\" class=\"schema-faq-section\"><strong class=\"schema-faq-question\">4. What defines Medical Decision Making (MDM) of high complexity?<\/strong>\r\n<p class=\"schema-faq-answer\">High complexity involves extensive treatment options, a lot of data review, and high risk of complications.<\/p>\r\n<\/div>\r\n<div id=\"faq-question-1746010699217\" class=\"schema-faq-section\"><strong class=\"schema-faq-question\">5. How should time be documented for E\/M coding?<\/strong>\r\n<p class=\"schema-faq-answer\">Document the face-to-face time with the physician, detailing the nature of counseling or care provided.<\/p>\r\n<\/div>\r\n<div id=\"faq-question-1747319212254\" class=\"schema-faq-section\"><strong class=\"schema-faq-question\">6. What is CPT Code 99214 used for?<\/strong>\r\n<p class=\"schema-faq-answer\">CPT Code 99214 is used for office or outpatient visits with established patients that require moderate to high complexity in medical decision-making. It typically involves a detailed history, exam, and management of chronic or multiple conditions.<\/p>\r\n<\/div>\r\n<div id=\"faq-question-1747319231515\" class=\"schema-faq-section\"><strong class=\"schema-faq-question\">7. How do I know if CPT Code 99214 is appropriate for a visit?<\/strong>\r\n<p class=\"schema-faq-answer\">You can use CPT Code 99214 when the visit includes moderate complexity, detailed documentation, and meets Medicare&#8217;s medical necessity requirements. Ensure all elements\u2014history, exam, and decision-making\u2014are clearly documented.<\/p>\r\n<\/div>\r\n<div id=\"faq-question-1747319241033\" class=\"schema-faq-section\"><strong class=\"schema-faq-question\">8. Does time spent with the patient impact CPT Code 99214?<\/strong>\r\n<p class=\"schema-faq-answer\">Yes, but only if more than 50% of the face-to-face visit is used for counseling or coordination of care. Time-based coding must be clearly documented to support CPT Code 99214 billing.<\/p>\r\n<\/div>\r\n<div id=\"faq-question-1747319263758\" class=\"schema-faq-section\"><strong class=\"schema-faq-question\">9. What are the common mistakes in billing CPT Code 99214?<\/strong>\r\n<p class=\"schema-faq-answer\">Common mistakes include insufficient documentation, billing when medical necessity isn\u2019t met, or misunderstanding the complexity levels required. These can lead to denials or audits.<\/p>\r\n<\/div>\r\n<div id=\"faq-question-1747319278671\" class=\"schema-faq-section\"><strong class=\"schema-faq-question\">10. How can Medical Billers and Coders help with CPT Code 99214?<\/strong>\r\n<p class=\"schema-faq-answer\"><strong>Medical Billers and Coders <\/strong>ensure your CPT Code 99214 claims are properly documented, compliant, and reimbursed accurately. Our experienced team minimizes denials and helps streamline your E\/M billing.<\/p>\r\n<\/div>\r\n<\/div>\r\n","protected":false},"excerpt":{"rendered":"<p>CPT Code 99214 is commonly used for billing office or outpatient visits involving established patients with moderate to high complexity in medical decision-making. To meet the criteria for this level of Evaluation and Management (E\/M) service, proper documentation is critical. It requires a detailed history, detailed examination, and medical decision-making of moderate to high complexity. [&hellip;]<\/p>\n","protected":false},"author":9,"featured_media":10600,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[2],"tags":[2238,697,2239,2240,80,2241,162,192,815,816,2242],"class_list":["post-10599","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-medical-billing-services","tag-99214-guidelines","tag-accounts-receviables-audits","tag-cpt-code-99214","tag-cpt-code-99214-evaluation","tag-cpt-codes","tag-e-m-coding-for-outpatient-services","tag-medical-billing-and-coding-services","tag-medicare-medicaid-services","tag-outsourced-medical-billing-company","tag-outsourced-medical-billing-services","tag-patient-visit-codes-are-changing"],"yoast_head":"<!-- This site is optimized with the Yoast SEO Premium plugin v28.0 (Yoast SEO v28.0) - https:\/\/yoast.com\/product\/yoast-seo-premium-wordpress\/ -->\n<title>How to use CPT CODE 99214 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How should the History of Present Illness (HPI) be documented?","answerCount":1,"acceptedAnswer":{"@type":"Answer","text":"Document a detailed timeline of the patient\u2019s illness, including symptoms, severity, and timing.","inLanguage":"en-US"},"inLanguage":"en-US"},{"@type":"Question","@id":"https:\/\/www.medicalbillersandcoders.com\/blog\/how-to-use-cpt-code-99214-correctly\/#faq-question-1746010679888","position":3,"url":"https:\/\/www.medicalbillersandcoders.com\/blog\/how-to-use-cpt-code-99214-correctly\/#faq-question-1746010679888","name":"3. 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How should time be documented for E\/M coding?","answerCount":1,"acceptedAnswer":{"@type":"Answer","text":"Document the face-to-face time with the physician, detailing the nature of counseling or care provided.","inLanguage":"en-US"},"inLanguage":"en-US"},{"@type":"Question","@id":"https:\/\/www.medicalbillersandcoders.com\/blog\/how-to-use-cpt-code-99214-correctly\/#faq-question-1747319212254","position":6,"url":"https:\/\/www.medicalbillersandcoders.com\/blog\/how-to-use-cpt-code-99214-correctly\/#faq-question-1747319212254","name":"6. What is CPT Code 99214 used for?","answerCount":1,"acceptedAnswer":{"@type":"Answer","text":"CPT Code 99214 is used for office or outpatient visits with established patients that require moderate to high complexity in medical decision-making. 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Time-based coding must be clearly documented to support CPT Code 99214 billing.","inLanguage":"en-US"},"inLanguage":"en-US"},{"@type":"Question","@id":"https:\/\/www.medicalbillersandcoders.com\/blog\/how-to-use-cpt-code-99214-correctly\/#faq-question-1747319263758","position":9,"url":"https:\/\/www.medicalbillersandcoders.com\/blog\/how-to-use-cpt-code-99214-correctly\/#faq-question-1747319263758","name":"9. What are the common mistakes in billing CPT Code 99214?","answerCount":1,"acceptedAnswer":{"@type":"Answer","text":"Common mistakes include insufficient documentation, billing when medical necessity isn\u2019t met, or misunderstanding the complexity levels required. These can lead to denials or audits.","inLanguage":"en-US"},"inLanguage":"en-US"},{"@type":"Question","@id":"https:\/\/www.medicalbillersandcoders.com\/blog\/how-to-use-cpt-code-99214-correctly\/#faq-question-1747319278671","position":10,"url":"https:\/\/www.medicalbillersandcoders.com\/blog\/how-to-use-cpt-code-99214-correctly\/#faq-question-1747319278671","name":"10. How can Medical Billers and Coders help with CPT Code 99214?","answerCount":1,"acceptedAnswer":{"@type":"Answer","text":"<strong>Medical Billers and Coders <\/strong>ensure your CPT Code 99214 claims are properly documented, compliant, and reimbursed accurately. Our experienced team minimizes denials and helps streamline your E\/M billing.","inLanguage":"en-US"},"inLanguage":"en-US"}]}},"_links":{"self":[{"href":"https:\/\/www.medicalbillersandcoders.com\/blog\/wp-json\/wp\/v2\/posts\/10599","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.medicalbillersandcoders.com\/blog\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.medicalbillersandcoders.com\/blog\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.medicalbillersandcoders.com\/blog\/wp-json\/wp\/v2\/users\/9"}],"replies":[{"embeddable":true,"href":"https:\/\/www.medicalbillersandcoders.com\/blog\/wp-json\/wp\/v2\/comments?post=10599"}],"version-history":[{"count":16,"href":"https:\/\/www.medicalbillersandcoders.com\/blog\/wp-json\/wp\/v2\/posts\/10599\/revisions"}],"predecessor-version":[{"id":30075,"href":"https:\/\/www.medicalbillersandcoders.com\/blog\/wp-json\/wp\/v2\/posts\/10599\/revisions\/30075"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.medicalbillersandcoders.com\/blog\/wp-json\/wp\/v2\/media\/10600"}],"wp:attachment":[{"href":"https:\/\/www.medicalbillersandcoders.com\/blog\/wp-json\/wp\/v2\/media?parent=10599"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.medicalbillersandcoders.com\/blog\/wp-json\/wp\/v2\/categories?post=10599"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.medicalbillersandcoders.com\/blog\/wp-json\/wp\/v2\/tags?post=10599"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}