2021 Update: Understanding when to use 99214 CPT Code

On January 1, 2021, E/M coding updates took effect and level determination is now based on either time or medical decision making. Many health care professionals have embraced the new system, but questions remain about the activities that contribute to time allotment and medical decision-making levels. This blog takes a deeper dive into correctly coding for 99214.

Accurately coding for 99214 CPT- Level 4 Established Patient

The AMA© definition:

99214 CPT: 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 of total time is spent on the date of the encounter.

What qualifies as being an established patient?

There is more to the definition of a new or established patient than meets the eye. Of course, a new patient can be entirely new to the practice; however, there is another scenario. A new patient may be a patient that has been seen in the past. If a patient has not been seen within the last three years– in the same specialty, in the same group practice – they are considered a new patient. Established patients have been seen within three years in the same specialty in the same practice.

What is moderate medical decision making?

There are three elements to medical decision making: number/complexity of problems, number/complexity of data to be reviewed, and risk of morbidity.

According to the AMA, a problem is considered of moderate complexity if it contains any one of the following:

  • 1 or more chronic illnesses with exacerbation, progression or side effects of treatment
  • 2 or more stable chronic illnesses
  • 1 undiagnosed new problem with an uncertain prognosis
  • 1 acute illness with systematic symptoms
  • 1 acute complicated injury

The amount and complexity of data to review needs to fill at least one out of three categories:

  • Category 1: The review of at least three tests and/or documents or an assessment requiring an independent historian
  • Category 2: Independent interpretation of a test performed by another provider
  • Category 3: Discussion with an external health care professional about management or test results

And, there is a moderate risk of complication, illness, or injury from additional diagnostic testing or treatment (morbidity).

What activities count for physician time during the visit?

E/M time is still defined as face-to-face interactions between patients and qualified health providers (QHP), but other activities are included in the E/M time allotment:

  • Preparing to see a patient (i.e., review of tests)
  • Obtaining and/or reviewing a separately obtained history
  • Counseling and educating the patient/family/caregiver
  • Ordering medications, tests, or procedures
  • Referring and communicating with other health care professionals
  • Documenting clinical information in the patient record

The 99214 time allotment is between 30-39 minutes. Providers must record exact beginning and end times in the patient record.

Although coding is now mainly determined by time and medical decision making, health care professionals should still document patient history and perform examinations when appropriate. Providers are expected to use professional judgment to investigate or record anything relevant to patient care.


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