Office or other outpatient visit, established patient, level 4
Audit Defense & Denial Intelligence
Research-based denial patterns from OrbDoc Bill Analyzer
1. Upcoding - insufficient documentation for moderate MDM
Very CommonInsurance auditors downgrade 99214 to 99213 or 99212 when documentation doesn't clearly support moderate complexity medical decision-making. This is the #1 code on HHS's list of Medicare improper payments, with an estimated error rate of 25-35% in audits.
Common Causes
- • MDM components not clearly documented (must show 2 of 3: moderate problems, moderate data, moderate risk)
- • Assessment and plan lacks detail showing multiple problems or management options
- • Chronic stable conditions documented without evidence of medication adjustments or test review
Resolution Strategy
Provider must demonstrate moderate MDM with enhanced documentation showing: multiple problems addressed, data reviewed and considered, and moderate risk present. Success requires specific documentation, not general assertions.
2. Missing total time documentation (time-based coding)
Very CommonWhen billing 99214 based on time (30-39 minutes), the claim will be denied or downgraded if total time is not documented in the medical record. Time-based coding requires specific documentation.
Common Causes
- • No time documented anywhere in the note
- • Only face-to-face time documented (total time includes review, coordination, documentation)
- • Time documented but doesn't meet 30-minute threshold
Resolution Strategy
If contemporary time documentation exists (e.g., EHR timestamps), can be submitted with appeal. Retrospective time reconstruction is generally not accepted.
3. Same-day E/M with preventive visit
CommonBilling 99214 on the same day as a preventive visit (99395-99397) without Modifier 25 and clear documentation of a significant, separately identifiable problem will result in denial.
Common Causes
- • Minor problems addressed during preventive visit billed as separate E/M
- • Modifier 25 missing from problem-oriented E/M code
- • Documentation doesn't clearly separate preventive visit from problem-oriented visit
Resolution Strategy
Documentation must clearly show significant, separately identifiable problem requiring substantial additional work beyond preventive visit. Must demonstrate separate medical necessity.
💬 Plain Language Explanation
What this means
This is a more complex office visit. Your doctor spent more time with you, performed a more detailed examination, and made more complex medical decisions.
Why you might see this
This code is used when your visit required more time, a more detailed exam, or more complex medical decision-making than a standard visit. This could be because you had multiple concerns, needed a more thorough evaluation, or required more complex treatment planning.
Common context
Used for established patients with moderate complexity medical issues or multiple concerns.
What to ask your provider
"'What made this visit more complex than a standard visit? Can you explain why this level of service was necessary?'"
Relative Value Units (RVUs)
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Clinical Information
When to Use
Established patient visit with moderate complexity medical decision-making or 30-39 minutes total time
Common Scenarios
Documentation Requirements
- Comprehensive history including ROS and PFSH
- Detailed examination (2-7 organ systems documented)
- Moderate complexity medical decision-making
- OR document 30-39 minutes total time with activities
Coding Guidelines
Common Modifiers
Bundling Rules
- Cannot bill with preventive visit same day without modifier 25
- Subject to post-op global period restrictions
Exclusions
- Do not use for new patients (use 99204)
- Do not use for time <30 minutes (use 99213)
- Do not use for time ≥40 minutes (use 99215)
Coding Notes
Clinical scenarios
- Comprehensive history including ROS and PFSH
- Detailed examination (2-7 organ systems documented)
- Moderate complexity medical decision-making
- Comprehensive history including ROS and PFSH
- Detailed examination (2-7 organ systems documented)
- Moderate complexity medical decision-making
- Comprehensive history including ROS and PFSH
- Detailed examination (2-7 organ systems documented)
- Moderate complexity medical decision-making
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Frequently Asked Questions
CPT 99214 is the billing code for "Office or other outpatient visit, established patient, level 4". Established patient visit with moderate complexity medical decision-making or 30-39 minutes total time
Medicare pays approximately $125.18 for CPT 99214 (national average). Actual payment varies by geographic location due to GPCI adjustments. Hospital and commercial insurance rates are typically 2-4x higher than Medicare rates.
CPT 99214 has a total RVU of 3.66, broken down as: Work RVU 1.92, Practice Expense RVU 1.60, and Malpractice RVU 0.14. RVUs (Relative Value Units) determine Medicare reimbursement rates.
The most common denial reason for CPT 99214 is "Upcoding - insufficient documentation for moderate MDM". Insurance auditors downgrade 99214 to 99213 or 99212 when documentation doesn't clearly support moderate complexity medical decision-making. This is the #1 code on HHS's list of Medicare improper payments, with an estimated error rate of 25-35% in audits. Common causes include: MDM components not clearly documented (must show 2 of 3: moderate problems, moderate data, moderate risk); Assessment and plan lacks detail showing multiple problems or management options. Appeal success rate is approximately 40-60%.
Key documentation requirements for CPT 99214 include: Comprehensive history including ROS and PFSH; Detailed examination (2-7 organ systems documented); Moderate complexity medical decision-making; OR document 30-39 minutes total time with activities. Missing or incomplete documentation is a leading cause of claim denials for this code.
Bundling considerations for CPT 99214: Cannot bill with preventive visit same day without modifier 25. Subject to post-op global period restrictions Use an NCCI bundling checker to verify specific code combinations before billing.
Common modifiers for CPT 99214 include: 25 (When E/M separate from same-day procedure), 95 (Synchronous telehealth). Modifiers indicate special circumstances and can affect reimbursement or prevent claim denials.
The typical time requirement for CPT 99214 is 30-39 minutes total time on date of service. Time-based codes require documentation of the actual time spent providing the service.