What is the Difference Between CPT Code 99213 and 99214?

Introduction

Medical billing and coding play a crucial role in healthcare reimbursement, ensuring accurate compensation for services rendered by healthcare providers. Current Procedural Terminology (CPT) codes are used to describe medical, surgical, and diagnostic services. Among the most commonly used CPT codes for outpatient evaluation and management (E/M) visits are 99213 and 99214.

These codes apply to established patient office visits, but they differ in the level of service provided, the complexity of medical decision-making, and the reimbursement rates.

Overview of CPT Code 99213

CPT code 99213 is used for an established patient office visit that involves a moderate level of medical decision-making and evaluation. It is classified as a Level 3 E/M visit and is one of the most frequently billed codes in outpatient settings.

For a provider to bill 99213, the visit must meet the following criteria,

• History: Problem-focused or expanded problem-focused history
• Examination: Problem-focused or expanded problem-focused exam
• Medical Decision-Making (MDM): Low complexity
• Time Spent (If Time-Based): Typically, 20-29 minutes are spent with the patient (2021 guidelines)

CPT 99213 Code Medical Billing

• A patient visits for a follow-up on a stable chronic condition, such as hypertension or diabetes.
• A patient has an acute illness, such as an upper respiratory infection, but the symptoms are mild to moderate.
• The provider reviews basic lab results, prescribes a medication refill, and gives routine counseling.

CPT 99213 Code Medical Billing

The reimbursement for 99213 is lower than that of 99214, as it requires less time and complexity. Medicare and private payers have varying reimbursement rates, but on average, 99213 is reimbursed at approximately $92–$100 per visit.

Overview of CPT Code 99214

CPT code 99214 is also used for an established patient office visit, but it involves a higher level of complexity than 99213. It is classified as a Level 4 E/M visit and is associated with moderate to high medical decision-making.

• A patient with a chronic illness (e.g., diabetes, COPD, or heart disease) experiences a flare-up or worsening of symptoms, requiring a treatment adjustment.
• A patient presents with an acute illness that poses a significant risk, such as pneumonia or complicated migraine.
• The provider conducts an in-depth discussion about treatment plans, medication management, or lifestyle modifications for a chronic condition.
• A patient needs a referral to a specialist or additional diagnostic tests, such as imaging or lab work, due to a concerning symptom or abnormal finding.

Reimbursement for CPT 99214

Since 99214 represents a more detailed evaluation and complex decision-making, it is reimbursed at a higher rate than 99213. On average, Medicare reimburses 99214 at approximately $130–$150 per visit, depending on geographic location and payer policies.

How to Determine Whether Bill 99213 or 99214

Billing the correct E/M code depends on the level of medical necessity, documentation, and time spent. Here are some key considerations to determine whether to use 99213 or 99214:

1. Assess Medical Decision-Making Complexity
   • If the patient’s condition is stable and requires minimal decision-making, 99213 is appropriate.
   • If the provider must adjust medications, order new tests, or manage worsening symptoms, 99214 may be justified.
2. Evaluate the Time Spent with the Patient
   • If the provider spends 20-29 minutes, 99213 is the appropriate code.
   • If the provider spends 30-39 minutes, then 99214 is correct.
3. Review the Level of History and Exam
   • If only a problem-focused or expanded history/exam is performed, use 99213.
   • If a detailed history/exam is necessary, then 99214 is the right choice.
4. Ensure Proper Documentation
   • Detailed notes supporting the complexity of care, decision-making, and time spent are crucial for justifying 99214 over 99213.
   • Inadequate documentation may lead to claim denials or audits.

The Impact of Using the Right Billing Code

Choosing between 99213 and 99214 affects reimbursement, compliance, and patient care documentation. Under-coding (billing 99213 instead of 99214) may result in lost revenue while over-coding (billing 99214 instead of 99213) could lead to billing audits and penalties.

Common Pitfalls in Coding

• Under-documentation: Providers may perform services at a 99214 level but lack sufficient documentation, leading them to bill 99213 instead.
• Over-coding Risks: Billing 99214 without proper medical necessity or documentation can trigger audits and reimbursement recoupment.
• Failure to Use Time-Based Billing: If time is the primary determining factor, it must be clearly documented in the notes.

The Bottom Line

Understanding the difference between CPT codes 99213 and 99214 is essential for accurate medical billing, compliance, and optimized revenue. While both codes are for established patient visits, 99214 represents a more complex visit with detailed history, examination, and medical decision-making, leading to higher reimbursement.

To ensure proper coding:

• Accurately assess patient complexity and time spent.
• Document all necessary components thoroughly.

Use the appropriate code to reflect the level of service provided.