99214 vs 99213 is a topic of great interest for healthcare providers, particularly those who bill for outpatient services. These two Current Procedural Terminology (CPT) codes are used to describe evaluation and management (E/M) services provided by physicians and other eligible healthcare professionals. While both codes represent a significant portion of outpatient visits, they differ in terms of documentation requirements, medical decision-making complexity, and reimbursement rates.
99213 is a CPT code used to describe a level 3 E/M service, which typically involves a brief visit with a patient. This code is commonly used for routine office visits, follow-up visits, and minor illnesses or injuries. On the other hand, 99214 represents a level 4 E/M service and is typically used for more complex cases that require a higher level of medical decision-making. These may include patients with chronic illnesses, multiple medical problems, or complex medication regimens. It is important for healthcare providers to understand the differences between these two codes to ensure accurate billing and appropriate reimbursement.
Everything I said above is the “details” and the technical mumbo jumbo, but…..
Truth is, the difference between a 213 and a 214 is just one more stable chronic illness in most situations. This article is going to dive into convincing you to bill 214’s more often and get paid for the work you are doing!
Overview of CPT Codes 99213 and 99214
CPT codes 99213 and 99214 are commonly used by healthcare providers to bill for evaluation and management (E/M) services. These codes are used to describe the complexity and intensity of the medical decision-making process involved in providing patient care.
CPT code 99213 is used for a mid-level E/M service, while CPT code 99214 is used for a higher-level E/M service. The main difference between the two codes is the level of medical decision-making involved in providing patient care.
A healthcare provider may use CPT code 99213 when providing a patient with a straightforward medical issue that requires a limited examination and medical decision-making. On the other hand, a healthcare provider may use CPT code 99214 when providing a patient with a more complex medical issue that requires a detailed examination and medical decision-making.
The table below provides a comparison of the key components of CPT codes 99213 and 99214 according to the insurers and AAPC:
| Component | CPT Code 99213 | CPT Code 99214 |
|---|---|---|
| History | Problem-focused or expanded problem-focused | Detailed |
| Examination | Problem-focused or expanded problem-focused | Detailed |
| Medical Decision-Making | Straightforward | Moderate to high complexity |
| Time | 15-20 minutes | 25-30 minutes |
It is important for healthcare providers to accurately code their E/M services using the appropriate CPT code to ensure proper reimbursement and avoid potential audits. Healthcare providers should carefully document the level of medical decision-making involved in providing patient care to support the use of a particular CPT code.
In summary, CPT codes 99213 and 99214 are used to describe the complexity and intensity of the medical decision-making process involved in providing patient care. Healthcare providers should use the appropriate CPT code based on the level of medical decision-making involved in providing patient care and ensure accurate documentation to support the use of the code.
Using Medical decision making or MDM is the easiest way to justify billing a level 4. This chart dictates what goes into billing based on MDM. As you can see, you need 2 of the 3 categories in the chart. in the far left category, most patients have 2+ stable chronic illness’s. Then in the far right column, you do prescription drug management on almost all patients in the form of “continue lisinopril”.
Using time is okay, but you could be asked to prove the time you spent, this is why I prefer to use MDM as the main decision making method for billing level 4 visits.
RVU’s for the Visit
RVU for 99213 is about 1.3 wRVU’s, whereas RVU for a 99214 is 1.92 wRVU. So, if you bill 99214 more often you are going to be getting an extra .62 RVU for your work per patient! That adds up over the day. If you see 20 patients a day, that is an extra 10 RVU per day, 50 per week, 200 per month, I think you get the picture! It adds up FAST!
Because of this I am a huge fan of trying to get you to bill 99214’s if the work justifies it.
Criteria for 99213
Medical Decision Making
Medical decision making (MDM) is an essential factor in determining the level of service provided to a patient. For a 99213 code, the MDM must be of low complexity. This means that the physician must evaluate the patient’s medical history, examine the patient, and make a diagnosis or treatment plan based on the patient’s condition. The physician must also consider the risk of complications, morbidity, and mortality associated with the patient’s condition.
Based on the AMA chart above 1 stable chronic illness and prescription drug management constitutes a 3. Using MDM is EASY! The weird thing is so many people are still doing time based billing.
Just make it a level 4 and talk about one more stable chronic illness. Minimally more documentation for 0.6 more RVU per visit. 0.6 RVU more per visit is 46% more RVU’s per visit than compared to a level 3.
Patient History
The patient’s history is another crucial factor in determining the level of service provided. For a 99213 code, the physician must obtain a detailed history of the patient’s present illness, including the chief complaint, history of present illness, review of systems, and past medical, family, and social history. The physician must also document the patient’s medications, allergies, and immunization status.
Examination
The examination is the final factor in determining the level of service provided. For a 99213 code, the physician must perform a detailed examination of the affected body area(s) and related organ systems. This includes a review of the patient’s vital signs, general appearance, and pertinent physical findings. The physician must also document any abnormal or significant findings.
In summary, to qualify for a 99213 code, the physician must meet specific criteria for medical decision making, patient history, and examination. These criteria ensure that the physician provides a level of service that is appropriate for the patient’s condition.
Criteria for 99214
When it comes to selecting the appropriate level of evaluation and management (E/M) code for a patient encounter, it is important to understand the criteria for each level of service. In this section, we will discuss the criteria for selecting a 99214 code.
Complexity of Medical Decision Making
One of the key factors in determining whether a 99214 code is appropriate is the complexity of medical decision making involved in the encounter. This includes the number of diagnoses or management options considered, the amount and/or complexity of data reviewed, and the risk of complications or morbidity/mortality associated with the patient’s condition.
MDM is one of the easiest categories to justify billing for 99214 more often. If you talk about 2 or more stable chronic conditions and mention anything about prescription drug management, then it qualifies for a level 4. Most PCP visits are easily a level 4 visit. Even if you just review their blood pressure and cholesterol values, and tell them to continue their medications, then that is 2 stable chronic illnesses and prescription drug management.
Obviously make sure you do a history and exam, but using MDM or the time requirement are the easiest ways to justify a Level 4 visit.
Detailed Patient History
Another factor to consider when selecting a 99214 code is the level of detail included in the patient’s history. This includes a comprehensive review of the patient’s chief complaint, history of present illness, past medical history, family history, social history, and review of systems. The history should be relevant to the patient’s presenting problem(s) and should demonstrate a thorough understanding of the patient’s overall health status.
Comprehensive Examination
Finally, a comprehensive examination is also important when determining whether a 99214 code is appropriate. This includes a detailed examination of the affected body area(s) and related organ systems, as well as a general multi-system examination if indicated by the patient’s presenting problem(s).
Overall, selecting the appropriate E/M code requires careful consideration of the patient’s individual needs and the complexity of the medical decision making involved in the encounter. By following the criteria outlined above, providers can ensure that they are accurately capturing the level of service provided and receiving appropriate reimbursement for their services.
Comparing 99213 and 99214
When it comes to medical billing and coding, there are two commonly used codes for office visits: 99213 and 99214. Both codes are used to describe visits for established patients, but they have some key differences. In this section, we will compare the two codes and highlight their differences.
Time Requirements
One of the main differences between 99213 and 99214 is the time requirement. 99213 requires a minimum of 15 minutes of face-to-face time with the patient, while 99214 requires a minimum of 25 minutes. This means that if the visit lasts less than 15 minutes, the provider should use 99212 instead of 99213. Similarly, if the visit lasts between 15 and 24 minutes, the provider should use 99213, and if it lasts 25 minutes or more, the provider should use 99214.
Documentation Differences
Another difference between 99213 and 99214 is the level of documentation required. 99214 requires more detailed documentation than 99213. For example, providers must document a comprehensive history, a comprehensive examination, and medical decision-making of moderate complexity for 99214. In contrast, providers only need to document an expanded problem-focused history, an expanded problem-focused examination, and medical decision-making of low complexity for 99213.
The above is all true, but remember…. focus on MDM. 2 stable chronic illnesses with prescription drug management and you can and should bill a level 4.
Billing and Reimbursement
The final difference between 99213 and 99214 is the billing and reimbursement rates. 99214 has a higher billing rate and is reimbursed at a higher rate by insurance companies. This is because 99214 requires more time and more detailed documentation than 99213, and overall constitutes a more complicated patient encounter.
The RVU difference adds up over time. 0.6 wRVU per patient difference doesnt sound like much, but add that to 900 visits a quarter and it is significant.
In conclusion, while both 99213 and 99214 are used to describe office visits for established patients, they have some key differences in terms of time requirements, documentation, and billing and reimbursement rates. It is important for providers to accurately code their visits to ensure proper reimbursement and avoid any potential audits or penalties.
My thoughts
If you can code a 99214, then do it. How many times do we sit with our patients and talk about 5 things, but 4 of the 5 are very simple and take a few minutes. It doesn’t matter how simple it is. If you talk about 2 stable chronic medical illnesses and discuss any prescription drug management, then it is a level 4.
Don’t cheat yourself out of more wRVU’s because it was “easy” or you are afraid of being audited. If it is a level 4 then document and code it a level 4. Don’t down code to protect an audit or make visits cheaper. Get paid for the work you are doing my friends.
I highly recommend documenting level 4 visits based on MDM and not time. This way if you have 15 or 20 minute appointments you don’t have to prove you spent x amount of minutes with the patient, MDM documentation and billing is easy and straightforward.
Talk about 2+ stable chronic illnesses and direct the patient to continue on their current medications and you will be justified in billing a level 4.