What is the CPT code 99214 billing guideline?
Asked by: Tamia Schinner | Last update: June 16, 2025Score: 4.3/5 (26 votes)
What are the rules for billing 99214?
According to CPT, 99214 is indicated for an “office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a detailed history, a detailed examination and medical decision making of moderate complexity.” [For more detailed ...
What is the CPT code 99214 charge?
CPT code 99214 is used for an office or other outpatient visit where the healthcare provider evaluates and manages an established patient. The visit must involve a detailed history, a comprehensive examination, and moderate complexity in medical decision-making.
What is the difference between 99213 and 99214 billing?
An expanded problem-focused history, consistent with a 99213, requires one to three HPI elements while a detailed history consistent with a 99214 requires four or more HPI elements.
What is the rule for coding a new patient visit?
At that visit, the cardiologist bills a new patient visit because he only interpreted the EKG, but did not see the patient face to face. Three-year rule: The general rule to determine if a patient is new” is that a previous, face-to-face service (if any) must have occurred at least three years from the date of service.
Medical Decision Making with CPT Code 99214
What is the golden rule of medical coding?
The golden rule of healthcare billing and coding departments is, “Do not code it or bill for it if it's not documented in the medical record.” Providers use clinical documentation to justify reimbursements to payers when a conflict with a claim arises.
What is the procedure code for new patient office visit?
CPT® code 99203: New patient office visit, 30-44 minutes | American Medical Association.
Can you bill a 99214 for telephone visit?
For the duration of the public health emergency, CMS and some private payers are allowing audio-only telephone calls to be billed in the same way as in-person visits and these visits will be paid in equivalent amounts as E&M codes 99212-99214.
Can you bill 99213 for a nurse visit?
The 99213 code is used by a wide range of healthcare professionals, including physicians, nurse practitioners, and physician assistants. It is typically used for office visits that require a moderate level of medical decision-making and complexity.
Does modifier 25 go on office visit or procedure?
Modifier 25 is used to signify that when a separate identifiable evaluation-and-management (E/M) service was performed, which can refer to two evaluation-and-management (E/M) services, or a procedure plus an E/M service.
What is the CPT code for home visit established patient?
99349: Home visit for the evaluation and management of an established patient requiring a detailed history, detailed examination, and moderate-complexity medical decision-making, typically 40 minutes spent face-to-face with the patient. For patients with more complex conditions needing ongoing management at home.
Can you bill 99214 for observation?
The patient remains in observation status on Friday. At that time, you document a detailed history, detailed exam and moderate-complexity medical decision making. The patient is discharged on Saturday. The correct codes for these services are 99219 (Thursday), 99214 (Friday) and 99217 (Saturday).
What is the CPT code for an annual wellness visit?
AWV Coding. The CPT codes for Annual Wellness Visits are G0438 for the initial visit and G0439 for subsequent visits. These codes are used to bill Medicare for comprehensive wellness assessments and personalized prevention plans. It is important to remember that code G0438 is for the first AWV only.
Can you bill 99214 twice in one day?
Documentation must be submitted with the claim to medically justify two services on the same day. The frequency restriction for CPT codes 99211 thru 99214 may be exceeded with medical justification.
What is the CPT code for additional 30 minutes?
CPT code 90840 serves as an add-on code for each additional 30 minutes of psychotherapy beyond the initial session. This code recognizes the flexibility required in mental health care to address the varying needs and complexities of individual cases.
What is billing code 99214?
CPT® code 99214: Established patient office or other outpatient visit, 30-39 minutes. As the authority on the CPT® code set, the AMA is providing the top-searched codes to help remove obstacles and burdens that interfere with patient care.
How to code an office visit?
To report, use 99202. Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; Straightforward medical decision making.
Do I need a modifier for 99214?
Does 99214 need a modifier? Modifiers can be used with 99214 if applicable. For example, you can add Modifier 25 to the E/M visit with 99214 if there was a “separately identifiable E/M on the same day of a procedure” (source: ACC). Or add modifier 22 if the procedure was extra complex.
Can you bill a telehealth and office visit on the same day?
E-visits should not be billed on the same day the physician reports an office visit E/M service (CPT codes 99202-99205 and 99211-99215) for the same patient. Additionally, e-visits should not be billed when using the following codes for the same communication: 99091.
When to bill 99213 vs 99214?
The primary difference between CPT code 99213 and 99214 lies in the complexity and time involved. While 99213 is for a low level of medical decision-making, 99214 is used for moderate complexity, requiring a higher level of medical decision-making and more extensive history and examination.
What is the 3 year rule for new patients?
By CPT definition, a new patient is “one who has not received any professional services from the physician, or another physician of the same specialty who belongs to the same group practice, within the past three years.” By contrast, an established patient has received professional services from the physician or ...
When not to use modifier 25?
Modifier 25 should not be used when: ❌ The sole purpose of the encounter is for the procedure (e.g., lesion removal), and there is no documented medical necessity for a separate E/M service.