CPT Code 99214,99213 E&M Coding Established Office Patient Correctly for Medicare Reimbursement

Learn how to correctly bill CPT Code 99214 instead CPT 99213 or CPT 99212 Codes for Evaluation and Management (E&M) Coding of Established Office Patient to increase revenue through legitimate Medicare reimbursement.

CPT Code 99214, if billed correctly, can increase revenue for the practice. By only using CPT code 99212 and CPT Code 99213 many providers are losing thousands of dollars in legitimate revenue yearly. It can be avoided with the correct billing of the 99214 E/M Code.

The CPT definition of a new patient underwent subtle changes in 2012. Unfortunately, CMS did not change their definition to stay aligned with these changes. This difference in language has caused great confusion for many qualified healthcare practitioners trying to stay compliant with the complex rules and regulations of E&M. 

Current 99214 CPT Code Description includes the comment note "Typically, 25 minutes are spent face-to-face with the patient and/or family.". So as per description notes the provider spends approximately 25 minutes face-to-face with the patient for billing CPT 99214.

It is important while selecting time-based CPT codes, that the provider must have spent a time closest to the code selected. For example, 99214 CPT code has a time of 25 minutes, and 99213 has a time of 15 minutes. If the Provider-Patient face-to-face encounter is 21 minutes, select code 99214 since the time spent is closer to 99214 than 99213 as specified in CPT description.

CPT Code 99214 is assigned to the medical service that complies with the following requirements: 

• The patient is an established one, meaning is not their first visit.
• It must be an outpatient visit, meaning it must not incorporate a day of hospital time.
• It must meet or exceed to of the following three points:
• A detailed medical history
• A detailed medical exam
• A medical decision that entails moderate complexity.

The severity of the problem that brings the patient to the clinic must be from a moderate to a high one. 5. And last, the doctor and the patient should have a maximum of 25 minutes face time.

CPT Code 99214 Increases Medicare Revenue

Medicare and other Insurance are pleased to pay the lesser money to providers if they (the doctors) are willing to under use the CPT code 99214. The key to using this code correctly is to understand the proper use and the components required to fully capture the most out of all of your encounters. 

As a provider, you will be rewarded the fruits of your labor when you take the time to learn the components of this code and use it properly.

When you consider CPT code 99214 it has a higher return rate linked to it, however, it must fall under the purview of a moderate complexity to a high severity problem. The physician, if using time as a factor must have spent at least 25 minutes in a face to face scenario with the patient. 

However, the time component is only a guide and not completely required if the components are included in the visit and the required medical necessity is present. The physician must be able to furnish the two or three areas which include history, physical exam and medical decision making with the proper documentation when filing for the CPT code 99214.

The patient encounter, composed of a detailed history, detailed patient exam and moderate complexity in the medical decision making will justify the use of CPT 99214 as long as the medical necessity is apparent.

For example, you have an established office patient with hypertension, diabetes and a history of dyslipidemia who you are seeing on follow-up in the office. Under the 1997 guidelines you can use three chronic and stable conditions to qualify for the higher code within the history component.

Document the medications and the review of systems along with the proper past medical, family and social history and the first component is met. Document the proper physical exam using appropriate organ system approach six areas with two bullets each and you have met the requirement for the complexity in this area.

At this point, technically you have reached the level 4 criteria since there only needs to be two out of three components required for an established patient.

However, we feel that it is difficult to not have a medical decision-making component so we include that in our progress note. You can document the lab results for the patient and further solidify the visit to qualify for the higher code. As long as the medical necessity is present to justify the work done during the visit the coding can be at the higher level.

99214 vs 99213 CPT Codes Billing

In above Example, most providers will code the example as a CPT 99213, however, the qualifiers are present for the higher CPT 99214 code.

While evaluating three different medical problems such as Hypertension, Diabetes, and Hyperlipidemia, using the 1997 rules, you have met the medical necessity component as well, due to the need to monitor these diseases and help the patient with his/her control.

However, meeting the proper criteria required to code the encounter will enable a medical biller to get the rewards for his career and his practice. It also becomes important, because nowadays Medical Billing and Coding Business are facing potential cuts in the reimbursements for the services the bill.