99214 CPT Code (2023) Description, Billing Guidelines & Clinical Examples
99214 CPT code bills for the service when the physician performs an evaluation and management service in the Office or other outpatient hospital visit to the established patient. It requires a medically appropriate exam and or history and a moderate level of medical decision making. If code selection basis on time, the physician needs 30-39 minutes of total time spent with that patient in same day encounter.
99214 CPT Code Description
99214 CPT code reports for established patients, The patients who did not receive any face-to-face service by the physician within the same specialty or sub-specialty within the past three years.
CPT codes 99211-99215 require a medically appropriate history and or examination, excluding the most basic service represented by 99211 that describes an encounter that may not require the presence of a physician or other qualified health care professional.
For the remainder of codes within this range, code selection basis on the level of medical decision-making (MDM) or total time personally spent by the physician and other qualified health care professional(s) on the encounter date.
Reasons to be considered in MDM include the risk of complications and or morbidity or mortality associated with patient management, the amount and complexity of data requiring review and analysis, and the count and severity of problems addressed during the encounter.
CPT code 99212 for a visit that entails straightforward MDM. If time uses for code selection, 10 to 19 minutes will be spent on the encounter day. CPT code 99213 for a visit requiring a low level of MDM or 20 to 29 minutes of the total time.
99214 CPT code reports a moderate level of MDM or 30 to 39 minutes of the total time. In contrast, CPT 99215 for a high level of MDM or 40 to 54 minutes of the whole time.
99214 CPT code bills for the service when the physician performs an evaluation and management service in the Office or other outpatient hospital visit to the established patient. It requires a medically appropriate exam and or history and a moderate level of medical decision making. If code selection basis on time, the physician needs 30-39 minutes of total time spent with that patient in same day encounter.
99214 CPT Code Reimbursement
A maximum of two units can be a bill on the same service date of 99214 CPT code. In contrast, the Three units allow documentation supporting the service’s medical necessity.
The cost and RUVS of CPT 99214 are $106.12 and 3.06650 when performed in the facility. In contrast, the reimbursement and RUVS of 99214 CPT code are $142.31 and 4.11225 when performed in the non-facility.
The performing provider may report telemedicine services by adding modifier 95 to these procedure codes. Services at the origination site report with HCPCS Level II code Q3014.
99214 CPT Code Modifiers
Modifier 33 is applicable with CPT 99214 when the physician performs preventive or mandated services to the patient. It does not apply to preventive services such as screening mammography, Lung cancer screening, etc.
Modifier 24 is applicable with CPT 99214 when the physician performs service to the patient in the post-operative period for an unrelated condition.
Modifier 25 is applicable with 99214 CPT code when the physician performs service to the patient on the same day- for an unrelated condition.
Modifier 27 is applicable with CPT 99214 when the physician performs multiple hospital outpatient services for the patient.
If physicians believe that Medicare will deny such service, reporting with a GA modifier is appropriate. The beneficiary must sign an Advance Beneficiary Notification (ABN), and CPT 99214 must apply the GA modifier to that service.
Modifier 57 is applicable with 99214 CPT code; when the physician decides to operate on the same date or one day before major surgical procedures, it is appropriate to report with modifier 57.
Modifier 95 is applicable with CPT 99214 when the physician performs the telehealth visit.
99214 CPT Code Billing Guidelines
Documentation should support the medical necessity of service. It reflects that service is medically necessary and appropriate.
99214 CPT code includes Established patients such as received prior professional services from a physician or qualified health care professional or another physician or skilled health care professional in the same specialty practice and subspecialty in the previous three years, office visits, and Outpatient services (including services before formal admission to the facility)
CPT 9924 reports only for Office or other outpatient services for an established patient. It requires medically appropriate history and physical examination, as determined by the treating provider, should be documented.
The history and physical examination level do not consider Office or other hospital outpatient visits 99211-99215.
According to CMS 2021 guidelines, Code selection will be based on MDM (Medical Decision Making) or on time.
If CPT 99214 selection is time-based, It includes face-to-face and non-face-to-face time personally spent by the physician or other skilled health care professional on the encounter date.
Unlike CPT 99214, CPT 99211 does not require the presence of a physician or other qualified health care professional.
CPT 99202-99205 reports s when the physician performs service to the new patient instead of established patient codes 99211-99215.
If the Emergency department (99281-99285) service performs in addition to CPT 99214, it is appropriate to report separately.
If the Hospital observation (99217-99220, 99224, 99225, 99226) performs in combination with CPT 99214, it is appropriate to report separately.
If the Hospital observation or inpatient with same-day admission and discharge (99234-99236) performs in combination with CPT 99214, it is appropriate to report separately.
99214 CPT Code Examples
The Following are the example when 99214 CPT code bills:
Example 1
A 58 y/o male with a PMH of HTN, HLD, and hypothyroidism presents to the hospital outpatient setting because of a headache and high blood pressure before arrival. The patient was lying down in bed at 10 pm when he began having a gradual onset pulsating frontal and occipital headache.
He reports the pain has become very severe. His headaches are usually associated with HTN, and when he took his BP, it was 210/100. He denies associated dizziness, chest pain, shortness of breath, motor weakness, numbness/tingling, abdominal pain, or nausea/vomiting.
Patient reports improvement in HA with Tylenol. The physician ordered a series of CT, MRI, and EKG diagnostic tests. EKG was independently interpreted and reviewed by the physician.
Example 2
51 y/o f with a history of HLD coming in for an episode of syncope/near syncope tonight, which her partner witnessed. She began using a Nicotine patch for the first time tonight.
One hour after using a nicotine patch while laying in bed, she had a brief episode of feeling hot, numbness, tingliness in her b/l hands, “gas discomfort” in her stomach, and headache.
When she tried to get up, she lost consciousness(witnessed by her partner, who I spoke to for more history). Partner states she was only out briefly before perking up to standard.
Pt states she has had episodes like this in the past but several years ago. No known cardiac history.
Physicians plan to order CBC, CMP, mg, phos, trop, EKG, Tylenol, Pepcid, and Zofran.
EKG: Normal sinus rhythm. 70 bpm. No ST elevation or T wave inversions.
CXR: My interpretation showed no acute abnormalities.
Example 3
36 yo male PMH HTN, HLD, Afib (on eliquis), Mitral valve replacement, gout presenting to the Office today for dark blood stools for two days. He states that he started having diarrhea yesterday and has had 4 BM in the past two days.
The patient denies nausea and vomiting. He denies CP, SOB, dizziness, fevers, or chills; Last took eliquis this morning. He also notes worsening bilateral lower extremity edema, for which he takes Lasix. He took Indomethacin for four days for a presumed gout flare.
The last colonoscopy three years ago found benign polyp but otherwise WNL. Physicians plan to admit and Plan Labs, EKG, CT abdomen and Pelvis, and prescribed Medicine.
Example 4
A 70 y.o female with a history of HLD presented to the OPD for substernal chest pain. She worked out daily, was a healthy, active senior, and lived at home. She was working out today.
After the workout, she took a sip of water and had substernal chest pain, none radiating, associated with weakness. However, Gatorate helped with the substernal chest pain.
She had no chest pain shortly after. However, her trainer told her to see a provider. She went to urgent care with asymptomatic resolved chest pain, and they sent her over here because she had a family history of MI.
Low suspicion for ACS. HEART score 3. Her brother died of MI at age 48 EKG without ischemic changes.
Example 5
38-year-old female past medical history of chronic gastritis diagnosed on endoscopic two weeks ago presenting with one month of on and off palpitations and lightheadedness.
The patient states that she has been feeling off for the last month and describes her symptoms as when she wakes up in the morning, she feels fogginess and has bouts of palpitations with associated lightheadedness without syncope.
The patient cannot pinpoint a trigger and states her symptoms resolve on their own—Palpitations last anywhere from seconds to minutes. The patient endorses that she has a healthy diet and does not do any narcotics drink alcohol or smoke.
Pt otherwise denies fevers, chills, syncope, headaches, neck pain, chest pain, shortness of breath, back pain, abdominal pain, nausea, vomiting, diarrhea, and constipation. The physician decided will obtain EKG labs, chest x-ray reassess
EKG normal sinus rhythm at 74 bpm with a QTC of 426, no ST elevations or depressions
More 99214 CPT Code Examples
Example 1
Office visit for an established patient now presenting with generalized dermatitis of 80% of the body surface area. (Dermatology)
Example 2
Office visit for a 32-year-old female, established patient, with new onset right lower quadrant pain. (Family Medicine)
Example 3
Office visit for reassessment and reassurance/counseling of a 40-year-old female, established patient, who is experiencing increased symptoms while on a pain management treatment program. (Pain Medicine)
Example 4
Office visit for a 30-year-old, established patient, under management for intractable low back pain, who now presents with new onset right posterior thigh pain. (Pain Medicine)
Example 5
Office visit for an established patient with frequent intermittent, moderate to severe headaches requiring beta blocker or tricyclic antidepressant prophylaxis, as well as four symptomatic treatment, but who is still experiencing headaches at a frequency of several times a month that are unresponsive to treatment. (Pain Medicine)
Example 6
Office visit for an established patient with psoriasis with extensive involvement of scalp, trunk, palms, and soles with joint pain, Combination of topical and systemic treatments discussed and instituted. (Dermatology)
Example 7
Office visit for a 55-year-old male, established patient, with increasing night pain, limp, and progressive varus of both knees. (Orthopaedic Surgery)
Example 8
Follow-up visit for a 15-year-old withdrawn patient with four-year-old history of papulocystic acne of the face, chest, and back with early scarring and poor response to past treatment, Discussion of use of systemic medication. (Dermatology)
Example 9
Office visit for a 28-year-old male, established patient, with regional enteritis, diarrhoea, and low-grade fever. (Internal Medicine)
Example 10
Office visit for a 25-year-old female, established patient, following recent arthrogram and MR imaging for TMJ pain. (Oral & Maxillofacial Surgery)
Example 11
Office visit for a 32-year-old female, established patient, with large obstructing stone in left mid-ureter, to discuss management options including urethroscopy with extraction or ESWL. (Urology)
Example 12
Evaluation for a 28-year-old male, established patient, with new onset of low back pain. (Anaesthesiology/pain Medicine)
Example 13
Office visit for a 28-year-old female, established patient, with right lower quadrant abdominal pain, fever, and anorexia. (Internal Medicine/Family Medicine)
Example 14
Office visit for a 45-year-old male, established patient, four months follow-up of L4-5 discectomy with persistent incapacitating low back and leg pain. (Orthopaedic Surgery)
Example 15
Outpatient visit for a 77-year-old male, established patient, with hypertension, presenting with a three-months history of episodic substernal chest pain on exertion. (Cardiology)
Example 16
Office visit for a 25-year-old female, established patient, for evaluation of progressive saddle nose deformity of unknown etiology. (Plastic Surgery)
Example 17
Office visit for a 65-year-old male, established patient, with BPH and severe bladder outlet obstruction, to discuss management options such as TURP. (Urology)
Example 18
Office visit for an adult diabetic established patient with a past history of recurrent sinusitis who presents with one-week history of double vision. (Otolaryngology/Head & Neck Surgery)
Example 19
Office visit for an established patient with lichen planus and 60% of the cutaneous surface involved, not responsive to systemic steroids, as well as developing symptoms of progressive heartburn and paranoid ideation. (Dermatology)
Example 20
Office visit for a 52-year-old male, established patient, with a 12-year-old history of bipolar disorder responding to lithium carbonate and brief psychotherapy, Psychotherapy and prescription provided. (Psychiatry)
Example 21
Office visit for a 63-year-old female, established patient, with history of familial polyposis, status post-colectomy with sphincter sparing procedure, who now presents with rectal bleeding and increase in stooling frequency. (General Surgery)
Example 22
Office visit for a 68-year-old male, established patient, with the sudden onset of multiple flashes and floaters in the right eye due to a posterior vitreous detachment.(Ophthalmology)
Example 23
Office visit for a 55-year-old female, established patient, on cyclosporine for treatment of resistant, small vessel vasculitis. (Rheumatology)
Example 24
Follow-up office visit for a 55 year-old male, two months after iliac angioplasty with new onset of contralateral extremity claudication. (Interventional Radiology)
Example 25
Office visit for a 68-year-old male, established patient, with stable angina, two months post myocardial infarction, who is not tolerating one of his medications. (Cardiology)
Example 26
Weekly office visit for 5FU therapy for an ambulatory established patient with metastatic colon cancer and increasing shortness of breath. (Hematology/Oncology)
Example 27
Follow-up office visit for a 60-year-old male, established patient, whose post-traumatic seizures have disappeared on medication and who now raises the question of stopping the medication (Neurology)
Example 28
Office evaluation on new onset RLQ pain in a 32-year-old female, established patient. (Urology/General Surgery/Internal Medicine/Family Medicine)
Example 29
Office evaluation of 29-year-old, established patient, with regional enteritis, diarrhoea, and low-grade fever. (Family Medicine/Internal Medicine)
Example 30
Office visit with 50-year-old female, established patient, diabetic, blood sugar controlled by diet, She now complains of frequency of urination and weight loss, blood sugar of 320 and negative ketones on dipstick. (Internal Medicine)
Example 31
Follow-up office visit for a 45-year-old, established patient, with rheumatoid arthritis on gold, methotrexate, or immunosuppressive therapy. (Rheumatology)
Example 32
Office visit for a 60-year-old male, established patient, two years post-removal of intracranial meningioma, now with new headaches and visual disturbance.(Neurosurgery)
Example 33
Office visit for a 68-year-old female, established patient, for routine review and follow-up of non-insulin dependent diabetes, obesity, hypertension, and congestive heart failure, Complains of vision difficulties and admits dietary noncompliance, Patient is counselled concerning diet and current medications adjusted. (Family Medicine)
