Complete Guide to CPT Code 99214

Medical Codes
November 26, 2025

For established patient office visits, CPT Code 99214 is one of the most frequently used, and often misunderstood, codes. This guide will provide a clear, detailed breakdown of what is cpt code 99214, how to use it correctly, and how it differs from other common codes.

What is CPT Code 99214?

CPT Code 99214 is an Evaluation and Management (E/M) code used for “Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and a moderate level of medical decision making.”

In simpler terms, it’s designated for established patient encounters that involve a moderate level of complexity. This code is used when a patient presents with a worsening or new problem, or when the management of their existing condition(s) requires a significant physician or qualified healthcare professional (QHP) effort. It represents a step up in complexity from code 99213.

99214 CPT Code Description

The description of CPT Code 99214 hinges on the level of Medical Decision Making (MDM). Since the 2021 E/M guidelines were updated, the history and examination elements are no longer scored for level selection. Instead, the code level is determined either by the total time spent on the patient on the date of the encounter or by the level of Medical Decision Making.

The core of the 99214 CPT code description is a visit that involves a moderate level of medical decision making.

Breaking Down Medical Decision Making (MDM) for 99214

Category	99214 Requirement	Examples
Number and Complexity of Problems Addressed	At least one acute illness with systemic symptoms, one chronic illness with exacerbation/progression/side effects of treatment, or two or more stable chronic illnesses	Asthma with moderate exacerbation; diabetes + hypertension needing prescription management; severe sinus infection with fever/fatigue
Amount and/or Complexity of Data to be Reviewed and Analyzed	Must meet Limited data criteria and at least one of: • Review of external notes • Independent interpretation of a test • Discussion of management/test with external physician	Reviewing consultant’s report; independently interpreting an X-ray/EKG; discussing care plan with a specialist
Risk of Complications and/or Morbidity or Mortality of Patient Management	Moderate level of risk	Prescription drug management; deciding on minor surgery with risk factors; treating a minor illness that could threaten bodily function if untreated

99214 CPT Code Description Time

As an alternative to using MDM, you can select CPT code 99214 based on total time. This is a critical change that offers flexibility.

Total Time for 99214: 30-39 minutes
- “Total time” is defined as the combined time spent by the physician or QHP on the date of the encounter.
- This includes both face-to-face and non-face-to-face time.
- Activities that count toward total time:
  - Preparing to see the patient (reviewing records)
  - Obtaining and/or reviewing separately obtained history
  - Performing a medically appropriate examination
  - Counseling and educating the patient/family/caregiver
  - Ordering medications, tests, or procedures
  - Referring and communicating with other healthcare professionals
  - Documenting clinical information in the EHR
  - Independently interpreting results and communicating that interpretation to the patient
  - Care coordination

Using time can be beneficial for visits that involve extensive counseling or coordination of care, even if the MDM might not clearly reach the “Moderate” level.

Application of Billing CPT Code 99214

Correctly applying code 99214 requires careful documentation. Your medical record must support the level of service billed.

Key Documentation Requirements:

Chief Complaint: Clearly state the reason for the visit.
History of Present Illness (HPI): Document a detailed HPI that reflects the complexity of the problem.
Assessment and Plan: This is where you justify the MDM.
- Problems: List the diagnoses and their nature (e.g., “uncontrolled hypertension,” “moderate asthma exacerbation”).
- Data: Note any external records reviewed, tests you interpreted, or discussions with other providers.
- Risk: Document the treatment plan, including any new prescriptions, decisions for minor surgery, or management of chronic conditions.
Time: If billing based on time, you must document the total time spent and a description of how the time was used (e.g., “Spent 35 minutes total on today’s encounter, with 20 minutes spent face-to-face counseling the patient on new diabetes medication and coordinating care with the endocrinologist.”).

Difference Between CPT Code 99213 and CPT Code 99214

Understanding the distinction between these two codes is essential for accurate billing and avoiding under- or over-coding.

Feature	CPT Code 99213 (Low Complexity)	CPT Code 99214 (Moderate Complexity)
Medical Decision Making (MDM)	Low	Moderate
Problems Addressed	One or more self-limited or minor problems; one stable chronic illness.	One chronic illness with exacerbation; two or more stable chronic illnesses; an acute illness with systemic symptoms.
Data Reviewed	Minimal or none. May involve a simple review of internal test results.	Requires a more significant review, often involving external data or independent interpretation.
Risk	Low risk management (e.g., rest, over-the-counter medication).	Moderate risk management (e.g., prescription drug management, minor surgery).
Total Time	20-29 minutes	30-39 minutes

99214 CPT Code Reimbursement

Reimbursement for CPT code 99214 varies significantly based on the payer (Medicare, Medicaid, private insurance), geographic location, and the setting of care. It is consistently reimbursed at a higher rate than 99213 due to the increased complexity and time involved.

It is critical to check with your specific payers and use the current year’s Physician Fee Schedule (PFS) from the Centers for Medicare & Medicaid Services (CMS) for the most accurate Medicare rates. Proper documentation and coding for 99214 directly and positively impact practice revenue, as it justly compensates for the higher level of care provided.

Conclusion

CPT Code 99214 is a vital code for representing moderate complexity established patient visits. Successfully and compliantly billing for this code requires a solid understanding of the modern Medical Decision Making criteria or the total time rule. By focusing on accurately documenting the complexity of the problems addressed, the data reviewed, and the risk of management, healthcare providers can ensure they are appropriately reimbursed for the significant clinical work they perform. Always remember that the medical record must tell the story of a moderate complexity visit to justify the use of 99214.