CPT 99213 and 99214 for Established Visits

What these two codes are

CPT 99213 and CPT 99214 are office or other outpatient evaluation and management codes for an established patient. They are not procedure codes. They describe the visit itself: the history and exam the clinician actually performed, or the medical decision making, or the total time spent on the date of the encounter when time is the basis the practice chose.

An established patient has been seen by the same specialty in the same group within the last three years. A new-patient code is a different family. Using 99213 because the face is familiar, while the group has no prior record, is a registration problem before it is a coding problem.

Why the level is not a habit

Many schedules drift toward one code. A practice that sends 99213 on almost every follow-up is not automatically undercoding, and a practice that sends 99214 on almost every follow-up is not automatically overcoding. The question is whether the note for that day supports the level that was selected.

99214 generally describes a visit with moderate medical decision making, or a longer documented time, compared with 99213. The precise time thresholds and the definitions of problems, data, and risk live in the current CPT and in the payer's policy. Those tables change. A blog post should not be treated as the fee schedule. The coder reads the year's definitions. This article only names the decision.

Time-based coding counts the clinician's time on the date of the encounter for the activities CPT includes, such as preparing, seeing the patient, and documenting. It does not count staff time at the front desk. If the note does not state the time, time is not the basis of the code.

What the note has to contain

For medical decision making, the note should show the problems addressed that day, the data reviewed or ordered, and the risk of the management. A problem list copied forward, with no statement of what changed, does not describe the visit. A medication refill can be straightforward or it can be part of managing a chronic illness that is not at goal. The note has to say which.

For a same-day procedure, an office visit is billed in addition only when the visit is significant and separately identifiable. Modifier 25 is the usual signal. It is not a default attachment. If the only work was the procedure, the visit code does not belong on the claim.

• Who the patient is to this group: established, or not.
• The problems addressed today, not the entire past history.
• Data reviewed, if data is being used to support the level.
• Risk of the treatment, if risk is being used to support the level.
• Total time, if and only if time is the basis.

What billing should not do

Do not raise a 99213 to a 99214 because the payer 'usually pays' the higher code. Payment is not documentation. Do not lower every visit to 99213 to feel safe. Undercoding is still a mismatch between the work and the claim, and it teaches the practice nothing about its notes.

Do not add a diagnosis to justify a level. The diagnosis on the claim comes from the assessment. A chronic code that was not addressed today is not a reason to select 99214.

If the note and the code disagree, the query goes back to the clinician before the claim goes out. A cleared query is a sentence in the chart. A guessed level is a denial, or worse, a pattern.

How this connects to the rest of the claim

An established-visit code still needs a correct patient, an active plan, a referring or ordering story when the payer wants one, and a charge that matches the place of service. Eligibility and coding are different steps. A perfect 99214 on an inactive plan is still an unpaid claim.

Relibill's coding page describes the review that happens before submission. This article is the definition of two common codes. It is not a client result and it is not a promise that any visit will be paid at a particular level.