Description of CPT code 99214 

CMS and the American Medical Association have announced big changes in E&M coding from 2021. The changes from 2021 only affect outpatient office visit codes (99201- 99215). There are also specific guidelines on which prolonged service codes can be used and how to use them. We will discuss more in details about the guidelines to follow for CPT code 99214.

The first noticeable change is the provider will no longer be required to document a specific level of history or examination. The new guidelines state documentation of an appropriate history or exam must be based on the patient’s symptoms and diagnoses.

Also from 2021, providers will have the ability to select the level of service based on time spent during the visit. Providers often spend longer time with some patients for relatively minor complaints. There are a myriad of reasons why this happens—extra time to review medical records, taking a history from another source, etc. The  guidelines allow the provider to select a higher E&M code based on time alone, even if the medical decision making is straightforward or low in complexity.

Medical decision making has always played a key role in the selection of the level of service. This will become the key element for code selection in 2021.

Here is one example of a change to a commonly used code — 99214.

Read also: New versus Established patient for E/M coding

E&M CPT code 99214 description till 2020:

99214 – Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 25 minutes are spent face-to-face with the patient and/or family.

E&M  CPT code 99214 description from 2021

99214 – 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.

When using time for code selection, 30-39 minutes is the amount of total time spent on the date of the encounter.

Providers report these codes for established patients being seen in the doctor’s office, a multispecialty group clinic, or other outpatient environment. All require a medically appropriate history and/or examination excluding the most basic service represented by 99211 that describes an encounter in which the presenting problems are typically minimal and may not require the presence of a physician or other qualified health care professional.

For the remainder of codes within this range, code selection is based on the level of medical decision making (MDM) or total time personally spent by the physician and/or other qualified health care professional(s) on the date of the encounter. Factors to be considered in MDM include the number/complexity of problems addressed during the encounter, amount and complexity of data requiring review and analysis, and the risk of complications and/or morbidity or mortality associated with patient management. Report 99212 for a visit that entails straightforward MDM.

Coding tips for CPT code 99214

• Know what a normal pre-treatment review includes. A quick check of the patient’s condition is part of the treatment and will include the following work: Ask the patient about any changes to his pain. Ask whether the patient started or stopped taking any medications. Determine whether any factor would prevent the doctor from performing the treatment.
• Use unexpected findings to justify an E/M code. When a doctor discovers something that requires him to re-evaluate the decision to perform an injection, he may be able to bill the visit. For example, when the patient comes in for the second injection, she mentions she felt a tingling in her mouth and throat a few hours after the first injection. The doctor decides to cancel the injection and does a work up of the patient to make sure she is all right and create another plan of care.

RVUs for CPT code 99214

XXX – Global days concept does not apply

Supply and Equipment codes used with 99214 CPT code

SA047 pack, EM visit
SM022 sanitizing cloth-wipe (surface, instruments, equipment)

EF023 table, exam
EF048 Portable stand-on scale
EQ189 otoscope-ophthalmoscope (wall unit)

TOP diagnosis ICD-10 codes for CPT code 99214

Hypertension (I10) 9.66%

Diabetes (E11.9) 6.59%

Chronic ischemic heart disease (I25) 3.56%

Dorsalgia (M25) 2.96%

Atrial fibrillation and flutter (I48) 2.66%

FAQ

Difference between CPT code 99213 & 99214?

If time is used for code selection, 10 to 19 minutes of total time is spent on the day of encounter. CPT code 99213 is reported for a visit requiring a low level of MDM or 20 to 29 minutes of total time; CPT code 99214 for a moderate level of MDM or 30 to 39 minutes of total time; and CPT code 99215 for a high level of MDM or 40 to 54 minutes of total time.

what is cpt code 99214 with modifier 25?

Modifier 25 may be appended to an Evaluation & Management (E&M) code when reported with another procedure or other service, on the same day of service to indicate a “significant and separately identifiable” E&M service when appropriate. Since 99214 is an E/M CPT code, 25 modifier should be used when the above condition is met.

Example : A patient visits the cardiologist for an appointment complaining of occasional chest discomfort during exercise. The patient has a history of hypertension and high cholesterol. After the physician completes an office visit it is determined that the patient needs a cardiovascular stress test that is performed that day by the same physician.

Coding for Example : The physician or other qualified healthcare provider codes an E/M visit (99202 – 99215) and the physician or other qualified healthcare provider also codes for the cardiovascular stress test (93015). The Modifier 25 is added to the E/M visit to indicate that there was a separately identifiable E/M on the same day of a procedure.

Coded CPT codes:

99214, 25

93015  Cardiovascular stress test 

What is the cost or fees or reimbursement rate of CPT code 99214?

Anyone who wants to know the Medicare pay Procedure cost for a particular CPT code like 99214, you can visit the below link. Different options like multiple code search, modifiers and specific MAC locality can be entered for specific info.

https://www.cms.gov/medicare/physician-fee-schedule/search

 You need to enter the CPT code in HCPCS Box and you will get the results for reimbursement rate, pay, fees or cost of all the MAC region or locality as shown below

Detailed Physical Exam Includes:

• Extended exam of the affected body region or organ system: For the purposes of examination these body areas are recognized – Head, including the face; Neck; Chest, including breasts and axillae; Abdomen; Genitalia, groin, buttocks; Back, including spine; and Each extremity
• Symptomatic/related body systems or organ systems: For the purposes of examination these organ systems are recognized – 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

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

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

Code G0463, Hospital outpatient clinic visit for assessment and management of a patient, is reported by hospitals only to represent clinic visits under OPPS for Medicare beneficiaries. Medicare does not recognize CPT codes 99202–99215 for hospital outpatient clinic visits for Medicare beneficiaries.

Code selection for office and outpatient services (99202–99205 and 99212–99215) is based on total time for E/M services OR level of medical decision making (MDM). When using time, the total time on the date of the encounter is applied and includes face-to-face and non-face-to-face time personally spent by the physician or other qualified health professional (QHP). It does not include time for activities performed by clinical staff. The levels of MDM are defined based on three elements: number and complexity of problems addressed at the encounter; amount and or complexity of data to be reviewed and analyzed; and risk of complications and/or morbidity or mortality of patient management.

Reference:

https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf