CPT Code 99214 – What are CPT codes?
The Current Procedural Terminology (CPT) coding system is developed by the American Medical Association (AMA). This coding system makes documentation of healthcare data, medical services, and administrative management, such as insurance claims and billing processes, accurate and efficient.
The CPT codes are standard and numerical, used worldwide for proper communication across stakeholders, patients, and therapeutic services.
The CPT codes are used to report medical, surgical, and laboratory services along with evaluation and management (E/M) and many other healthcare services.
CPT code 99214:
CPT code 99214 covers an office or any other outpatient visit to evaluate and manage an already-established patient.
Who is an established patient?
An established patient is one who had been seeking healthcare services from the same healthcare provider or another healthcare provider of the same specialty for the past three years.
How do we code 99214?
The 99214 indicates a level-IV established patient visit. This visit involves a detailed history, detailed examination, and MDM (medical decision-making) of a moderate level.
A medical history and examination with moderate medical decision-making are required. According to the revised criteria, 30 to 39 minutes of the total time is spent on the visit. The actual time for evaluation and management (E&M) and the level of medical decision-making decide which code must be selected.
The total time spent includes the face-to-face or non-face-to-face encounter of physicians or healthcare professionals with the patient, and it excludes time taken for other activities performed by clinical staff. Similarly, the levels of medical decision-making are based on the complexity of problems and data to be reviewed and the risk of morbidity or mortality.
Medicare doesn’t recognize CPT code 99214 for hospital outpatient clinic visits. Only the necessary services during the visit can be considered for determining the code.
A detailed medical history is needed to assess the level of medical decision-making, the time necessary for encounters, and the evaluation and management of outpatients.
A detailed medical history includes the following components:
- A chief complaint
- An extended history of the present illness
- A thorough review of systems
- Patient’s past family and social history
It is a statement made by the patient about their problem describing the symptoms.
History of present illness:
While describing the present illness, the following components are considered:
- The location of the problem
- The quality of the signs and symptoms
- The severity of signs and symptoms
- The duration of the illness
- The modifying factors
- Signs and symptoms that are related to the presenting complain
Review of systems (ROS):
For the detailed exam, the affected body region or organ systems are examined head, face, neck, chest (including the breasts and axilla), abdomen, genitalia, groin, buttocks, back, and all the extremities are examined.
The body systems that are recognized are constitutional (such that vital signs, general appearance, fever, and weight loss), eyes, ears, nose, mouth, and throat, cardiovascular system, respiratory system, gastrointestinal system, genitourinary system, musculoskeletal system, skin, neurologic examination, psychiatric examination, and lymphatic examination.
Documenting the history for 99214:
According to the CPT guidelines, a detailed history documents the following:
- At least four elements in HPI (history of present illness) or
- at least three inactive/chronic conditions.
- A review of two to nine organ systems.
- Patient’s past, family, or social history (PFSH).
Before documentation, it must be kept in mind that according to CPT guidelines, only two of the components mentioned above are required to select the service being provided. Hence, the 99214 can be coded on the basis of history and medical decision-making without worrying about the detailed review of systems or all elements.
Similarly, the requirement to document the detailed history is sometimes fulfilled in the patient’s previous visit. For example, you will fulfill the ROS requirement by asking questions about the symptoms based on their last visit. The same goes for the PFSH documentation.
Hence, to meet the criteria for documenting a detailed history, one has only to note some details of the presenting complaint, the responses to the review of the affected organ system and at least one other system, and a medication review with some aspects of PFSH.
Medical decision-making in 99214:
99214 code accounts for the decision-making of moderate complexity. It’s based on any two of the following factors.
- The number of diagnoses (differential diagnoses) or management options under consideration
- The amount and complexity of the data provided
- The extent of risk (for both acute and planned interventions)
Although determining the decision-making level is difficult, if the provider is dealing with several medical problems, has several data elements to review, and has a higher uncertainty level, they may document moderate decision-making.
Summarising CPT Code 99214:
Counseling or coordination of care (CC):
HPI: 4+ elements (or 3+ chronic diseases)
ROS: 2-9 systems
PFSH: 1 element
1997 documentation guidelines: 12 or more elements
1995 documentation guidelines: 5-7 systems
CPT® code 99214: Established patient office visit, 30-39 minutes ; American Medical Association.
How to use CPT CODE 99214 Correctly? ; medicalbillersandcoders.com.
Jitendra M. Sc CPC; CPT Code 99214 coding tips for Medical Coders; Medical Coding Guide; 2021.
Bill Dacey, MBA, MHA, CPC, CPC-I; New coding guidelines a recipe for improved revenue; PHYSICIANS PRACTICE; 2020.
EMILY HILL, PA-C; How to Get All the 99214s You Deserve; AAFP; 2003.
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