For healthcare providers in private practices, choosing the correct evaluation and management (E/M) code can be challenging. Not to mention costly if errors occur. 

Among the most common codes, CPT 99214 stands out. This current procedural terminology (CPT) code refers to a level 4 established patient outpatient visit, often requiring moderate complexity medical decision-making or a specific total time spent on the encounter.

In 2023, CPT code 99214 was the single most frequently misreported E/M service to Medicare, according to 2024 Medicare fee-for-service (FFS) supplemental improper payment data. The United States Department of Health and Human Services (HHS) reported an overall estimated Medicare FFS improper payment rate of 7.66%, representing $31.70 billion in its fiscal year 2024 agency financial report.

Its place at the top of the improper payments list is concerning, especially since it was also the most-billed level 1 CPT code submitted to Medicare, based on the most recent Centers for Medicare & Medicaid Services (CMS) data. For healthcare providers and medical billing teams, improving CPT 99214 compliance could have a measurable impact on both revenue integrity and the national improper payment rate.

According to the supplemental improper payment data, CPT code 99214 generated $564,563,132 in improper payments in 2023. Of that total, more than 63% stemmed from incorrect coding, while 20.1% resulted from missing documentation and 16.5% from insufficient details in the medical record.

For healthcare professionals, these lapses can delay reimbursement and increase the risk of denials or even audits. Ultimately, this affects patient care and coordination of care.

Other notable findings from the CMS data include:

The American Medical Association actually reports that under the 2025 Medicare Physician Fee Schedule, the conversion factor used to calculate payments (including for CPT code 99214) dropped to $32.3465, a 2.83% decrease from 2024. This reduction reflects tighter reimbursement rates nationally.

The E/M changes that took effect January 1, 2021, have made it much easier to select the right level of service for an outpatient visit. For CPT code 99214, providers can base the choice on the total time spent with the patient or the level of medical decision making (MDM). You should use the method that accurately reflects the reason for the visit.

When the MDM method is applied, moderate complexity usually means the patient has one or more chronic conditions that are getting worse, two or more stable chronic conditions, or an acute illness with systemic symptoms. The updated AMA E/M FAQs go into much more detail on how to apply these rules. They also include what to consider when reviewing data and determining medical necessity.

To meet the documentation requirements for 99214, the record should include:

CPT code 99213 is used for visits with lower complexity or shorter duration, often between 20 and 29 minutes. CPT code 99214 is suited to visits that involve more complexity or take longer, reflected in its higher reimbursement rate.

The 5 steps below outline how to apply CPT code 99214 correctly during an E/M visit or office visit. Each step highlights ways to provide accurate coding, maintain proper documentation, and avoid common medical coding errors like undercoding.

To bill based on time, a provider must meet or exceed 30 minutes of total time on the date of the patient encounter. This threshold applies to established patients under CPT code 99214. 

Suppose the practice uses an electronic health record (EHR) with a built-in time calculator. In that case, it can make code selection easier and help coders ensure accurate reporting. Ideally, this documentation should include the total time and a brief description of the tasks completed during that visit.

In addition to face-to-face time in the exam room or during a telehealth session, "total time" also counts preparation and follow-up work on the same day. This may include reviewing tests and taking a detailed history or social history. 

It can also involve completing a physical exam or physical examination of relevant organ systems and body systems. Other qualifying activities include discussing the patient's condition or providing counseling to the patient or their caregiver. Billing by time can be useful when lower-acuity visits still require extended physician involvement.

According to the 99214 billing guidelines, at least 2 of the 3 elements of medical decision-making must meet the moderate level criteria. These elements are the number and complexity of problems addressed, the amount and complexity of data reviewed and analyzed, and the risk of complications or morbidity and mortality. 

The MDM table from the American Medical Association can help with accurate code selection and prevent errors in medical coding. Using this reference is an important part of proper documentation for both patient visits and follow-up care.

Adding the current medication list to the progress note does not justify counting prescription drug management toward the MDM. There must be evidence in the documentation that a physician has evaluated medications as part of a service they provided. 

Documentation should also reflect a direct connection between the medication and the work performed on the day of the visit. In addition, physicians cannot count labs at the time of the order and when they review them at the follow-up appointment. They should only count them on the date on which they order them, per the American Medical Association (AMA).

According to the AMA, CPT code 99214 is most often used for established patients with a progressing illness or acute injury that requires medical management or possible surgical treatment. Depending on the present illness and treatment plan, this can include cases involving moderate risk or even high complexity. 

While this guideline can help streamline the billing code decision, it does not cover every scenario. Providers should also compare the visit requirements for 99213, and when in doubt, review documentation for accuracy before submitting to the payer or adding a modifier.

To avoid CMS improper payments, exclude any separately billable services from your MDM or total time calculation for an office visit. This article from the American Academy of Family Physicians offers examples showing how to document 99214 accurately based on time or MDM, along with tips for E/M coding. 

This whitepaper from the AMA explains how to ensure clinical documentation supports the chosen E/M code, whether for an established or new patient, and how to record relevant medical history.

When justified, reporting 99214 helps maintain revenue integrity. As with all E/M codes, clinical documentation must clearly show why 99214 is the correct choice. If the record does not support the billing guidelines, providers should not submit the code. 

To prevent Medicare improper payments, follow compliance best practices and review the guidelines before choosing the E/M level.