When to bill 99213 vs 99214?
Asked by: Dr. Christ Doyle | Last update: December 19, 2025Score: 4.7/5 (35 votes)
When should I use 99213?
CPT® code 99213: Established patient office or other outpatient visit, 20-29 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.
What qualifies for a 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 an example of a 99213 visit?
An example of a 99203 or 99213 is a sinus infection treated with an antibiotic. Although the prescription makes the risk component moderate, the one acute uncomplicated illness is a low-complexity problem, and there are no data points.
What is the difference between 99213 and 99214 optometry?
For a 99213 office visit, six to eight elements are required for the exam component; for a 99214 visit, nine elements are required. Both 99211 and 99215 account for less then 2% of total office visits in eye care for established patients. This is representative of what I see in our office.
Medical Coding 99213 vs 99214 - MDM Medical Decision Making Explained
How do you know if its 99213 or 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.
Can 99213 be billed for telehealth?
These services should be billed using standard E/M codes. For example, a level 3 office visit provided to an established patient via telehealth should be billed using code 99213.
What does a 99213 reimburse?
Accurate Reimbursement for Moderate Complexity Services
Physical therapy sessions vary widely in complexity. CPT Code 99213 allows physical therapists to accurately bill for visits that involve moderate complexity, rather than assigning a lower code that may not fully capture the level of service provided.
How many minutes is 99214?
CPT® code 99214: Established patient office visit, 30-39 minutes | American Medical Association.
What is the billing code for follow up visits?
Follow-up visits, like initial visits, should be coded using the appropriate evaluation and management (E/M) code (i.e., 99211–99215).
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.
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.
What is code 99214 used for?
CPT defines a 99214 or level-IV established patient visit as one involving a detailed history, detailed examination and medical decision making of moderate complexity.
Is 99213 a preventive code?
However, if you bill an additional office visit code (for example, 15 minute expanded problem visit code 99213 with modifier 25), this is NOT considered a preventive service, and may be subject to deductibles, copays or coinsurance.
What is a complex office visit?
Complex visits are defined as those with over two diagnoses (the mean of diagnoses made per visit) and/or those with over three prescription medications (the mean of medications prescribed per visit).
What is the difference between 99213 and 99214 in 2024?
Code 99213 typically represents a visit involving low to moderate complexity and shorter duration, while 99214 indicates a visit with moderate to high complexity and longer duration.
What is considered an office visit?
An office visit is any direct personal exchange between an ambulatory patient and a physician or members of their staff for the purpose of seeking care and rendering health services.
Does 99214 require dilation?
Therefore, some exam elements may not be performed. A detailed history and moderate decision making are appropriate for 99214. The physician should perform the exam elements based on medical necessity; often this includes dilation.
What are the rules for 99213?
- Medical Necessity: Healthcare providers need to explain why the visit was needed. ...
- Time-based Documentation: Providers need to spend 20-29 minutes with the patient, which is surely required to help them with decision-making.
Can you bill 99213 with modifier 25?
If the E/M is not bundled into the stress test, then the Cardiologist's coder can use modifier 25 to indicate that these two services were separate and significant: 99213-25, 93015.
What is the 7 day telehealth rule?
The communication cannot be related to a medical visit within the previous seven days and cannot lead to medical visit within the next 24 hours (or soonest appointment available). Physician or other clinician may respond to patient by telephone, audio/video, secure text messaging, email, or patient portal.
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.
What is modifier 59 in medical billing?
The CPT Manual defines modifier 59 as: “Distinct Procedural Service: Under certain circumstances, it may be necessary to indicate that a. procedure or service was distinct or independent from other non-E/M (Evaluation/Management) services.