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What is CPT Code 99214? How To Use CPT Code 99214 Correctly?  

How to Accurately use Code CPT 99214 - Coding Tips for Medical Coders

In the world of medical billing and coding, accuracy is very important. One code that stands out is CPT Code 99214. It’s not just a number; it helps make sure healthcare providers get paid fairly while following the rules.

This guide will explain CPT Code 99214 in simple terms for healthcare workers. Whether you’re experienced or new to the field, it’s important to know how to use this code correctly. It helps ensure proper payments and good care for patients. Let’s explore this code, learn what it means, and understand how it can impact healthcare and patient care.

CPT Code 99214 – Description and Requirements

CPT codes 99214 is used to bill for an established patient office visit that involves a moderate level of medical decision making (MDM) or takes 30-39 minutes of total time on the date of the encounter. It is part of the evaluation and management (E/M) services.

99214 CPT Code Description

  1. Procedure Code 99214 in medical billing is an important part of medical billing. It shows a specific level of evaluation and management (E/M) service.
  2. This code belongs to a group of CPT codes, ranging from 99211 to 99215, that classify the complexity and intensity of E/M services.

Requirements of 99214 procedure code

To use medical code 99214 correctly, healthcare providers must carefully document all details in the patient’s medical record. Complete and accurate documentation is important to justify using this code and to ensure proper payment for the services given.

Providers should also follow specific rules set by payers, like Medicare or private insurance companies, to avoid problems with claims or audits.

  1. Patient Visit Type: Providers must accurately identify the type of patient visit (e.g., routine check-up, follow-up, or emergency). The type of visit affects the level of service and code that can be applied.
  2. Complexity of Service: Complexity of the service provided should align with the selected 99214 procedure code. Providers must ensure that the documentation reflects the appropriate level of complexity for the patient’s condition and treatment.
  3. Evaluation and Management: Providers must follow the correct criteria for Evaluation and Management (E/M) services, such as documenting the patient’s history, physical examination, and medical decision making. This helps ensure the correct code is used based on the level of care given.
  4. Documentation: Proper documentation is essential to justify the chosen code. Providers must thoroughly document the patient’s condition, the services provided, and any relevant information to meet payer guidelines and avoid claim denials or audits.

These requirements ensure that Code 99214 is billed correctly and reflects the care given to the patient.

How to Properly Assign 99214 CPT code? Simple Guide for Accuracy

CPT Codes 99214 is important for billing Evaluation and Management (E/M) services. To use this code correctly, follow these simple guidelines:

How to Properly Assign 99214 CPT code
  1. Medical Necessity: Use 99214 CPT code only when the service is needed to treat the patient’s health issue. The treatment should directly address the patient’s condition and be necessary for their care.
  2. Documenting the Current Illness: Record a clear timeline of how the patient’s illness developed, starting with the first signs or symptoms. Include details like where the symptoms are, how severe they are, and if anything makes them better or worse.
  3. Chief Complaint: Write down the patient’s main reason for the visit, whether it’s a symptom, problem, diagnosis, or follow-up visit.
  4. Review of Symptoms: Ask the patient about different body systems (like fever, weight loss, or issues with organs) to get a full understanding of their health. Make sure to document everything the patient mentions.
  5. Detailed Physical Exam: Conduct a thorough physical exam, especially of the body part or system that is affected. Record your findings in detail.
  6. Patient History: Review the patient’s past illnesses, treatments, and family medical history. This helps understand any conditions that could affect their current health.
  7. Detailed History: Include information about the patient’s current health problem, their symptoms, and relevant family or social history.
  8. Medical Decision Making (MDM): To use 99214 CPT code, the decision-making should be of high complexity. This means the diagnosis or treatment options, amount of data to review, and risk level should be significant.
  9. Time Based Billing: If more than half of the time spent with the patient is for counseling or coordinating care, document how much time you spent on these activities.
  10. Comorbidities: If the patient has other health conditions that make their care more complicated, include them in the decision-making process. However, the focus should mainly be on the patient’s current problem.
  11. Signature Requirement: Make sure all services for Medicare patients are signed, either by hand or electronically, following Medicare rules.
  12. Avoid Late Signatures: Instead of adding signatures after the fact, use the signature authentication process to stay compliant.
  13. Properly Code the Encounter: Make sure to assign 99214 CPT code to the visit in the claim or your electronic health record system. Include any diagnosis codes (ICD-10) that explain the patient’s condition and show why the visit was necessary.
  14. Ensure Compliance: Always follow the coding and billing rules set by insurance companies, including Medicare. Keep accurate records to support the codes you use.

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Criteria for Qualifying as a Level 4 Office Visit

CPT Codes 99214 is typically used for office or outpatient visits where the patient’s medical issues are of moderate to high complexity. To qualify for a level 4 visit (99214), the following criteria must be met:

Criteria for Qualifying as a Level 4 Office Visit - cpt code 99214
  1. History: The provider must gather a detailed history of the patient’s present illness, review of systems, and past medical, family, and social history.
  2. Examination: The provider must conduct a detailed examination of the patient’s affected body systems and any related organ systems.
  3. Medical Decision Making (MDM): Provider should evaluate multiple diagnoses or treatment options, review several sources of clinical data, and consider the risk of complications or issues related to the patient’s condition.
  4. Time Spent with the Patient: Provider should spend at least 30 to 39 minutes face-to-face with the patient and/or family. More than half of this time must be spent on counseling or coordinating care.

By meeting these requirements, healthcare providers can correctly use 99214 procedure code to ensure proper billing and reimbursement for their services.

Can You Code CPT 99214 If the Patient Doesn’t Meet Level IV Visit Criteria?

Procedure code 99214 in medical billing should only be used if the documentation in the patient’s medical record clearly supports a level 4 visit based on the criteria for history, examination, and medical decision-making.

If the patient does not meet the criteria for a level 4 visit, the medical coder should not assign CPT codes 99214.

It’s important for medical coders to accurately reflect the level of service provided, based on the documentation in the patient’s medical record. Incorrectly assigning procedure code 99214 in medical billing when the visit doesn’t meet the necessary criteria could result in overpayment or underpayment for healthcare providers and might raise concerns about compliance with billing and coding rules.

If the documentation does not support a level 4 visit, the coder should review the patient’s records to choose the correct code. This may involve selecting a lower-level CPT code, such as 99213, or another E/M code that aligns with the visit’s documentation.

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How do medical billing services ensure the proper use of 99214 procedure code?

Medical billing services are essential in ensuring 99214 procedure code is used correctly and in managing healthcare providers’ overall revenue cycle. Here’s how they contribute:

  1. Expertise in Medical Coding and CPT Codes:
    Medical billing services employ experts who understand medical coding, including 99214 CPT code. They know the guidelines and criteria for this code, ensuring it’s applied correctly to each patient visit.
  2. Reviewing Documentation:
    Billing services review the documentation healthcare providers submit for each patient visit. They check that the necessary details for CPT Codes 99214, like the patient’s history, symptoms, examination, and medical decisions, are fully documented.
  3. Coding Accuracy:
    After reviewing the documentation, medical coders assign the appropriate CPT Code, such as 99214, based on the complexity of the visit. They make sure the code reflects the care given to the patient accurately.
  4. Compliance and Regulation:
    Billing services ensure the codes assigned follow the rules set by government agencies (like CMS), insurance companies, and industry standards. This helps healthcare providers avoid audits and penalties.
  5. Revenue Maximization:
    Using the correct CPT Code, like 99214, is key to ensuring healthcare providers receive the right amount of payment for services. Medical billing services help practices maintain financial stability by ensuring accurate and timely reimbursement.
  6. Avoiding Undercoding and Overcoding:
    Billing services help find the right balance between undercoding (which can lead to lost revenue) and overcoding (which can cause audits, penalties, and legal issues). They ensure the correct codes are used for complex patient encounters.
  7. Denial Management:
    If claims are denied or rejected, medical billing services find the cause, fix any errors, and resubmit the claims quickly. This prevents revenue loss and ensures providers are paid for their services.
  8. Education and Training:
    Some billing services offer training to healthcare providers and their staff on the importance of proper documentation and coding. This improves compliance and helps ensure the correct codes are used in the future.

Discover the Benefits of Partnering with Enfinity Medical Billing

At Enfinity, we offer exceptional medical billing services designed to help your practice thrive. Our deep understanding of CPT codes, including the proper use of Code 99214, ensures that your billing process is accurate and compliant. We specialize in providing tailored billing services for various specialties, helping reduce claim denials and maximize your revenue potential.

With Enfinity, you’ll experience a noticeable reduction in accounts receivable (AR) days, ensuring faster payments. Our efficient billing cycle and focus on improving clean claim rates guarantee a smoother financial workflow for your practice.

We also provide detailed monthly reports that give you valuable insights to help guide your financial decisions. Partner with Enfinity and experience a fresh approach to medical billing, where optimizing your revenue and maintaining compliance are our top priorities.

For more information about how Enfinity can improve your medical billing process, reach out to us at info@enfinitymedicalbilling.com or call us at +1 (732) 944-0080.

We focus on providing you with financial peace and security!

FAQs – CPT code 99214

What is CPT code 99214 used for?

CPT code 99214 is used for billing a Level 4 office visit with an established patient. This visit usually involves a more detailed check-up and care for the patient’s health condition compared to a Level 3 visit.

What is the difference between CPT code 99213 and 99214?

CPT codes 99213 and 99214 are used for billing evaluation and management (E/M) services for established patients in an office or outpatient setting. CPT code 99213 is assigned for a Level 3 visit, which typically involves a basic medical evaluation and management of a patient’s health condition. On the other hand, CPT code 99214 is used for a Level 4 visit, which requires a more detailed and complex medical evaluation and management of the patient’s condition.

What are 99214 CPT code time requirements?

As per the 2021 Current Procedural Terminology (CPT) Manual, the typical time for a Level 4 established patient office visit (CPT 99214) ranges from 30 to 39 minutes.

CPT code 99214 description?

CPT code 99214 is described as: “Office or other outpatient visit for the evaluation and management of an established patient, requiring at least two of these three key components: a detailed history, a detailed examination, and medical decision-making of moderate complexity.”

What is the CPT code 99214?

CPT code 99214 is for a Level 4 office visit for an established patient involving moderate complexity evaluation and management.

How many times a year can you bill 99214?

If a physician conducts more than two high-complexity visits (CPT 99214 or 99215) in a year, the MCO is responsible for reducing the payment to the rate for CPT 99213, without altering the CPT code or requiring the physician to do so.

What is 99213 used for?

CPT 99213 is used for Level 3 visits with low complexity evaluation and management.

What does CPT stand for?

CPT stands for Current Procedural Terminology.

What is the CPT code for E&M?

Common E&M codes include 99202–99215, depending on the patient and visit complexity.

Why do we use 25 modifier in medical billing?

Modifier 25 is used to indicate a significant, separately identifiable evaluation and management service on the same day as another procedure.

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