Is 99214 Being Billed Too Often?

99214 represents a code that is the second highest level of care for an established office patient.  This code ranks second among the most frequently used CPT codes in the world.  Internists use this code for 37% of established office patients and should probably use it more often than they do. 

The definition of 99214 is as follows:

The documentation for this encounter requires two out of three of the following:

1.  Detailed History

2.  Detailed Exam

3.  Moderate Complexity Medical Decision-Making

Or 25 minutes spent face-to-face with the patient if coding based on time.  The appropriate documentation must be included.

A study has been done showing that from 2001 to 2010, physician’s increased using code 99214 which is a higher-level and more lucrative billing code for evaluation and management (E/M) services in the course of treating Medicare patients.  During that time, the volume of Medicare payments for E/M services rose 48%, whereas spending for all Medicare Part B goods and services increased 43%.  In 2010, E/M services accounted for 30% of all Medicare B expenditures.

Dramatic changes occurred with 99213 and 99214 visits.  In 2001, the midrange 99213 visit represented 54% of the pie, and the 99214 visit, 21%.  In 2010, the share for 99213 had slipped to 46%, whereas that for 99214 stood at 36%- a 15% increase over 2001.

The jump from 99213 to 99214 yielded a big increase in compensation.  In 2010, Medicare paid on average $97.35 for a 99214 visit, which is 50% more than the $64.80 for a 99213.

One suggested but unproven explanation for higher E/M coding says that Medicare patients are sicker than they were in 2001, prompting physicians to be with the patient longer in order to evaluate and diagnose them and to manage their conditions.

A physician in Florida states that an aging population means more complex care and there is a significant increase in obesity, which is driving a rise in adult-onset diabetes.  Patients are also on many more mediations than recent years.

Over the years physicians have undercoded with 99213 due to lack of documentation and chose to play it safe and settled for a lower reimbursement in the process.  Even if they did thoroughly document the visit in their notes, they often would code 99213 to avoid being accused of overcoding, or their patient chart notes were not complete, not thorough and lacked information.  Any practice management consultant would say, such physicians “left money on the table”.

Undercoding has been a problem for primary care physicians who depend on E/M services for the bulk of their income.  So the push has been to turn undercoders not into overcoders but accurate coders.   Just some food for thought….

Marina Hall is a Certified Medical Reimbursement Specialist (CMRS) and founder of MariAnn Medical Billing Service. To read a full “Interview with Marina Hall” visit her website at

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