CPT Code 99214 is a core code in outpatient evaluation and management services. It is used when an established patient presents with a condition that requires moderate to high complexity in medical decision-making. This code reimburses at a higher rate than 99213 and reflects more time, effort, or complexity.

For providers who manage chronic illness, handle new symptoms with potential complications, or perform risk assessments, 99214 is one of the most important billing codes to understand.

What Is CPT Code 99214?

99214 is a billing code used for outpatient visits involving established patients who require a moderate to high level of medical decision-making. This type of visit usually goes beyond a routine check-up. It often involves ongoing management of chronic illnesses, interpretation of diagnostic results, or significant risk assessments.

Under the updated 2021 E/M guidelines, this code can also be billed based on time. A visit that takes between 30 to 39 minutes, including both face-to-face and same-day related work, qualifies under time-based billing. The provider may choose the documentation approach that best reflects the service provided. (if billing by time)

Unlike 99213, which is for more routine care, 99214 addresses more serious or multi-faceted medical concerns.

When Should CPT 99214 Be Used?

Use 99214 when the visit involves multiple aspects of care that require in-depth evaluation and coordination. If a patient has several chronic conditions, such as diabetes and heart disease, and the provider needs to adjust medications, order labs, and assess symptoms that could indicate a change in the patient’s condition, this level of service may be warranted.

This code is also appropriate when discussing potential treatment risks or managing symptoms that could lead to more serious complications. Providers who take the time to explain various care options, consult with specialists, or manage unstable conditions will likely meet the criteria for 99214.

For example, if a diabetic patient presents with worsening symptoms and needs medication changes and lab work, this visit may qualify as 99214.

Time vs. Medical Decision-Making

There are two ways to justify the use of CPT 99214: time and complexity. If you’re using time as the basis, make sure to track all related work done on the day of the encounter. This includes chart review, patient communication, documenting the visit, and care coordination, in addition to the face-to-face interaction.

Alternatively, if you rely on medical decision-making, the provider must demonstrate moderate complexity. This involves analyzing multiple sources of data, managing several conditions, or facing treatment options with moderate risk. Your notes should reflect the effort and thought process involved in reaching your clinical decisions.

Providers should choose the method that most accurately reflects the work done.

Reimbursement Rates and Insights

CPT 99214 generally reimburses between $110 and $130, though exact amounts vary based on the payer and region. Because of the higher complexity, this code is subject to closer scrutiny.

Make sure documentation clearly shows why this level of service was necessary.

Best Practices for Documentation

Good documentation is the backbone of accurate coding and reimbursement. Be sure to clearly describe the patient’s conditions and explain the clinical reasoning behind each decision. If you adjust medications, order new tests, or discuss treatment risks, include those details in the chart.

Outline the complexity of the case by explaining why the visit required a higher level of engagement. This protects your practice during audits and helps justify the code in case of payer review..

FAQ: CPT Code 99214

What’s the difference between 99213 and 99214?
99214 is used for more complex visits involving multiple conditions, longer discussions, or moderate risk. It also allows for more reimbursement.

How long should a 99214 visit last?
If billing based on time, it should last between 30 and 39 minutes.

Can nurse practitioners use this code?
Yes, qualified non-physician providers can bill 99214 if documentation supports it.

Is prior authorization needed for 99214?
Usually not. But check with your payer for specific requirements.

How much does 99214 pay?
It typically reimburses around $110 to $130 depending on location and insurance.