A cheat sheet is a quick reference guide that provides information on a particular topic in a concise and easy-to-understand manner. In the medical field, cheat sheets can be especially helpful when it comes to coding and billing. One common area where healthcare providers may need assistance is in distinguishing between the 99213 and 99214 evaluation and management (E/M) codes.
The 99213 and 99214 codes are used to bill for office visits, and they are often used interchangeably. However, there are specific criteria that must be met in order to accurately code for each level of service. The 99213 code is used for a mid-level office visit, while the 99214 code is used for a higher level of service. Understanding the differences between these codes can be challenging, which is why a cheat sheet can be a valuable tool for healthcare providers.
In essence a 99213 is 1 stable chronic issue or minor acute issue and a 99214 is 2 or more stable chronic medical issues or 1 acute issue that involves systemic symptoms, both with prescription drug management involved.
This is using MDM
Time based requirements are different, but I rarely advise you use time based requirements.
Understanding CPT Codes 99213 and 99214
Criteria for 99213
CPT code 99213 is used to describe a level 3 office visit for an established patient. To qualify for this code, the visit must meet two out of three of the following criteria:
- A detailed history (every visit has this)
- A detailed examination (every visit has this)
- Medical decision making of low complexity ( 1 stable medical issue and prescription drug management)
During a level 3 office visit, the healthcare provider typically spends 15-20 minutes with the patient.
Criteria for 99214
CPT code 99214 is used to describe a level 4 office visit for an established patient. To qualify for this code, the visit must meet two out of three of the following criteria:
- A comprehensive history
- A comprehensive examination
- Medical decision making of moderate complexity (2+ stable chronic medical illnesses and prescription drug management)
During a level 4 office visit, the healthcare provider typically spends 25-30 minutes with the patient, but you don’t have to as long as you are billing based on MDM and not time.
In conclusion, understanding CPT codes 99213 and 99214 is important for healthcare professionals and medical billers to ensure accurate billing and reimbursement. By knowing the criteria for each code, healthcare providers can properly document their visits and bill for the appropriate level of service provided to their patients.
Key Differences Between 99213 and 99214
When it comes to medical billing, there are two codes that are commonly used for office visits: 99213 and 99214. While these codes may seem similar, there are some key differences that healthcare providers should be aware of.
Time Spent
One of the main differences between 99213 and 99214 is the amount of time spent with the patient. According to the American Medical Association (AMA), 99213 is used for office visits that last approximately 15 minutes, while 99214 is used for visits that last approximately 25 minutes.
Medical Decision Making
Another important factor to consider when choosing between 99213 and 99214 is the level of medical decision making involved in the visit. Medical decision making refers to the complexity of the medical problem(s) being addressed during the visit, as well as the amount of data reviewed and analyzed.
99213 is typically used for visits that involve straightforward medical problems, while 99214 is used for visits that involve more complex medical issues. For example, a patient with a simple cold or minor injury would likely be billed under 99213, while a patient with multiple chronic conditions or a complex medical history would likely be billed under 99214.
Patient Complexity
Finally, the complexity of the patient can also play a role in determining whether to use 99213 or 99214. Patient complexity refers to factors such as age, overall health, and the presence of multiple chronic conditions.
For example, an elderly patient with multiple chronic conditions would likely require more time and attention during an office visit, and would therefore be billed under 99214. On the other hand, a healthy young adult with a minor issue would likely be billed under 99213.
In summary, choosing between 99213 and 99214 requires careful consideration of factors such as time spent, medical decision making, and patient complexity. By understanding these key differences, healthcare providers can ensure that they are billing accurately and appropriately for their services.
Practical Usage in Medical Billing
Documentation Requirements
When billing for medical services using the 99213 and 99214 codes, it is important to ensure that the documentation meets the requirements set forth by the Centers for Medicare and Medicaid Services (CMS). The documentation must include the following elements:
- Chief complaint
- History of present illness
- Review of systems (not required anymore)
- Past medical, family, and social history
- Physical examination
- Medical decision making
For a 99213 visit, the documentation must support a low to moderate level of medical decision making, while a 99214 visit must support a moderate to high level of medical decision making. The documentation must also support the level of complexity of the patient’s condition and the amount of time spent with the patient.
Billing Scenarios
When determining whether to bill a 99213 or 99214 code, it is important to consider the complexity of the patient’s condition, the amount of time spent with the patient, and the level of medical decision making involved.
A 99213 code may be appropriate for a patient with a stable chronic condition who requires a limited exam and straightforward management. On the other hand, a 99214 code may be appropriate for a patient with a complex condition who requires a detailed exam, extensive history, and moderate to high level of medical decision making.
It is important to note that billing for a higher code than is supported by the documentation may be considered fraudulent and can result in penalties and fines. It is always best to ensure that the documentation accurately reflects the complexity of the patient’s condition and the level of medical decision making involved. If you bill a 4, make sure you have a full exam and 2+ stable chronic illness’s with a full HPI.
In summary, understanding the documentation requirements and billing scenarios for the 99213 and 99214 codes is essential for accurate medical billing. Healthcare providers should ensure that their documentation accurately reflects the complexity of the patient’s condition and the level of medical decision making involved to avoid potential penalties and fines.
Common Pitfalls and Compliance
Upcoding and Downcoding
Upcoding and downcoding are common pitfalls that healthcare providers should be aware of when selecting the appropriate level of service for a patient encounter. Upcoding occurs when a provider selects a higher level of service than what is warranted by the patient’s medical condition and the services provided. Downcoding, on the other hand, occurs when a provider selects a lower level of service than what is warranted by the patient’s medical condition and the services provided.
Upcoding can result in overpayment by insurance companies and government programs, while downcoding can result in underpayment and potential audits. It is important for providers to accurately document and code each encounter to avoid these pitfalls.
Audit Triggers
Audits can be triggered by various factors, including high utilization rates, unusual billing patterns, and coding errors. Providers should be aware of these triggers and take steps to avoid them.
One common trigger is high utilization rates, which can be caused by overuse of certain services or procedures. Providers should carefully monitor their utilization rates and ensure that they are providing services that are medically necessary and appropriate for each patient.
Another trigger is unusual billing patterns, such as billing for services that are not typically provided together or billing for services that are not typically provided by a particular specialty. Providers should review their billing patterns regularly and ensure that they are in compliance with all billing and coding guidelines.
Finally, coding errors can also trigger audits. Providers should ensure that their coding is accurate and up-to-date, and that they are using the correct codes for each encounter. Regular training and education can help providers avoid coding errors and stay in compliance with all regulations.
Cheat Sheet Tips
Quick Reference Guide
When it comes to coding and billing for medical services, it’s important to understand the difference between the codes 99213 and 99214. These codes refer to office or outpatient visits and are used to determine the level of service provided to the patient. Here are some quick tips to help you determine which code to use:
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99213: This code is used for a level 3 visit, which is a low to moderate complexity visit. This code is appropriate when the patient presents with a single or straightforward problem that requires a limited amount of medical decision-making.
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99214: This code is used for a level 4 visit, which is a moderate to high complexity visit. This code is appropriate when the patient presents with multiple or complex problems that require a significant amount of medical decision-making (think 2+ stable chronic illness’s that involve continuing a medication or adding a new one, with a full HPI, and physical exam.)
Best Practices
When using the 99213 and 99214 codes, there are some best practices to keep in mind:
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Always document the visit thoroughly: Accurate and detailed documentation is essential to ensure that the correct code is used. Make sure to document the patient’s history, examination, and medical decision-making.
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Use the correct code: Choosing the correct code is important to ensure that the provider is reimbursed appropriately for the services provided. Make sure to review the documentation carefully and choose the code that best reflects the level of service provided.
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Stay up to date on coding guidelines: Coding guidelines can change frequently, so it’s important to stay up to date on any changes to ensure that you are using the correct codes and billing practices.
By following these tips and best practices, providers can ensure that they are accurately coding and billing for their services, which can help to improve patient care and the financial health of their practice.
Check out the table below to understand 213’s vs 214’s in a simple way.
Remember, always document to meet the code. If you bill a 4, it better have 2+ stable chronic illness’s and a full HPI and exam. YOU HAVE TO DOCUMENT TO REFLECT WHAT YOU BILL.
That being said, it is super simple with templates to meet the needs of a level 4 bill on nearly every visit.
| 99213 | 99214 |
| Include full HPI and physical exam | Include full HPI and physical exam |
| 1 stable chronic illness with medication management | 2+ stable chronic illness’s with medication management |
| 1 acute illness that has no systemic symptoms | 1 acute illness with systemic symptoms |
| 15 minutes of overall involvement with patient care | 30 or more minutes with overall involvement of patient care |