This 99214 CPT® lecture reviews the procedure code definition, progress note examples, RVU values, national distribution data and explains when this code should be used in the hospital setting. CPT stands for Current Procedural Terminology. This code is part of a family of medical billing codes described by the numbers 99211-99215. CPT® 99214 represents the mid-high (level 4) office or other outpatient established office patient visit and is part of the Healthcare Common Procedure Coding System (HCPCS). This procedure code lecture for established office patient visits is part of a complete series of CPT® lectures written by myself, a board certified internal medicine physician with over ten years of clinical hospitalist experience in a large community hospitalist program. I have written my collection of evaluation and management (E/M) lectures over the years to help physicians and non-physician practitioners (nurse practitioners, clinical nurse specialists, certified nurse midwives and physician assistants) understand the complex criteria required to stay compliant with the Centers for Medicare & Medicaid Services (CMS) and other third party insurance companies.
Make sure to also review my detailed lectures on CPT® 99213 and CPT® 99215, both part of my complete collection of CPT® lectures organized in one easy-to-find resource on Pinterest. You don't need to be a Pinterest member to get access to any of my CPT® procedure lectures. As you master these E/M procedure codes, remember, you have an obligation to make sure your documentation supports the level of service you are submitting for payment. The volume of your documentation should not be used to determine your level of service. The details of your documentation are what matter most. In addition, the E/M services guide says the care you provide must be "reasonable and necessary" and all entries should be dated and contain a CMS defined legible signature or signature attestation, if necessary.
My interpretations discussed below are based on my review of the 1995 and 1997 E&M guidelines, the CMS E&M guide and the Marshfield Clinic audit point system for medical decision making. These resources can be found in my hospitalist resources section. The Marshfield Clinic point system is voluntary for Medicare carriers but has become the standard audit compliance tool in many parts of the country. You should check with your own Medicare carrier in your state to verify whether or not they use a different criteria standard than that for which I have presented here in my free educational discussion. I recommend all readers obtain their own updated CPT® reference book as the definitive authority on CPT® coding. I have provided access through Amazon to the 2015 CPT® standard edition pictured below and to the right. CPT® 99214 is an office or other outpatient procedure code and can be used by any qualified healthcare practitioner to get paid for their office or other outpatient established patient services. The American Medical Association (AMA) describes the 99214 CPT® procedure code as follows:
An established patient is defined as an individual who has received professional services from a doctor or another doctor of the exact same specialty and subspecialty who belonged to the same group practice within the past three years.Make sure to also review my detailed lectures on CPT® 99213 and CPT® 99215, both part of my complete collection of CPT® lectures organized in one easy-to-find resource on Pinterest. You don't need to be a Pinterest member to get access to any of my CPT® procedure lectures. As you master these E/M procedure codes, remember, you have an obligation to make sure your documentation supports the level of service you are submitting for payment. The volume of your documentation should not be used to determine your level of service. The details of your documentation are what matter most. In addition, the E/M services guide says the care you provide must be "reasonable and necessary" and all entries should be dated and contain a CMS defined legible signature or signature attestation, if necessary.
99214 MEDICAL CODE DESCRIPTION
My interpretations discussed below are based on my review of the 1995 and 1997 E&M guidelines, the CMS E&M guide and the Marshfield Clinic audit point system for medical decision making. These resources can be found in my hospitalist resources section. The Marshfield Clinic point system is voluntary for Medicare carriers but has become the standard audit compliance tool in many parts of the country. You should check with your own Medicare carrier in your state to verify whether or not they use a different criteria standard than that for which I have presented here in my free educational discussion. I recommend all readers obtain their own updated CPT® reference book as the definitive authority on CPT® coding. I have provided access through Amazon to the 2015 CPT® standard edition pictured below and to the right. CPT® 99214 is an office or other outpatient procedure code and can be used by any qualified healthcare practitioner to get paid for their office or other outpatient established patient services. The American Medical Association (AMA) describes the 99214 CPT® procedure code as follows:
Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three components: A detailed history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 25 minutes face-to-face with the patient and/or family.
This medical billing code can be used for time based billing when certain requirements are met. However, documentation of time is not required to remain compliant with CMS regulations. If billed without time as a consideration, CPT® 99214 documentation should comply with the rules established by the 1995 or 1997 guidelines referenced above. The three important coding components for an established outpatient clinic note are the:
- History
- Physical Exam
- Medical Decision Making Complexity
- Detailed history: Requires 4 or more elements of the history of present illness (HPI) OR documentation of the status of THREE chronic medical conditions. One element from the past medical history or social history or family history is also required. The review of systems should inquire about the system directly related to the HPI and at least 2-9 additional systems.
- Detailed examination: 1997 guidelines require documentation of at least 12 elements identified by a bullet in two or more organ systems(s) or body area(s). Alternatively, documentation of six organ systems or body areas with at least 2 bullet elements each is allowed as well. 1995 guidelines require an extended examination of the affected body area(s) and other symptomatic or related organ system(s). The CMS E&M guide on pages 31 and 32 describes the acceptable body areas and organ systems on physical exam.
- Medical decision making of moderate complexity (MDM): This is split into three components. The 2 out of 3 highest levels in MDM are used to determine the overall level of MDM. The level is determined by a complex system of points and risk. What are the three components of MDM and what are the the minimum required number of points and risk level as defined by the Marshfield Clinic audit tool?
- Diagnosis (3 points)
- Data (3 points)
- Risk (moderate); The risk table can be found on page 37.
CLINICAL EXAMPLES OF 99214
What are some progress note documentation examples for a CPT® 99214, the level 4 established patient visit in an office or other outpatient setting? Most doctors use the subject, objective, assessment and plan (SOAP) note format. A 99214 note could look like this:
S) Abdominal pain. RLQ. Started yesterday. Constant. 8/10. Associated fever (at least 4 HPI). No nausea, chest pain, dizziness, shortness of breath (at least 2 additional ROS ). Nonsmoker (One element from social history).O) 120/80 80 Tmax 98.9 (three vital signs = one bullet) abdomen no masses, positive bowel tones, RLQ tender with guarding; lungs clear; heart no murmur, RRR; legs no edema; skin no rash, eyes, no icterus, no JVD, alert, mild distress. (at least 12 total bullets in 2 areas )A) Nothing neededP) Nothing needed
In this example history (subjective) and physical (objective) meet the requirements to get paid for a 99214. Remember, the highest 2 out of 3 components determine the highest level of service for established patients in the clinic or other outpatient setting. Do note that linking an ICD code to a CPT® medical code is required for all visits submitted to CMS for reimbursement. Therefore, most progress notes should provide at least one ICD code to clearly indicate a purpose for the visit. I suspect this is necessary to meet the reasonable and necessary threshold, unless that can be inferred from other chart documentation. Medicare doesn't want to pay for doctors to talk about football with their patients. There must always be an approved ICD code linked with the CPT® medical code when billed to CMS and most other insurance companies.
I think it's always a good habit to include at least on ICD code in your note documentation, even though it's not technically required for established patient clinic follow-up visits that can achieve compliance with history and physical elements alone. Remember, the highest supported level of documentation for 2 out of 3 from history, physical and medical decision making on established clinic patients determines the overall level of CPT® code service. For history, four elements of the HPI (character, onset, location, duration, what makes it better or worse etc...) or documentation of the status of three chronic medical conditions PLUS at least 2-9 additional review of systems in addition to inquiry about the HPI related problem PLUS at least one element of past medical, family, or social history is required for this level four progress note. For physical exam, using 1997 E/M guidelines, documentation of 12 bullets from at least two organ systems or body areas is required. Remember, documentation of three vital signs can count as one bullet element. Here is another clinical example of a SOAP note for a CPT® 99214 established patient clinic visit:
As you know, documenting the status of three chronic medical conditions can substitute for the HPI. Add in at least 2 additional review of systems and one element from past medical family and social history and this is the minimum history documentation required for CPT® 99214. With at least 12 bullets documented in the physical exam, this note is complete and accurate and meets documentation requirements to get paid for a 99214. All physical exam components offer value to the encounter to exclude potential complications of therapy or to search for evidence of decompensation of disease. While not necessary to remain compliant, this progress note example meets 3 out of 3 components (history physical AND MDM) for a level 4 established office visit. The medical decision making also meets criteria for a CPT® 99214 because it gets 3 points on diagnosis for describing the at least 3 medical conditions (DM, HTN, COPD) and moderate risk for ordering an ARB. Prescription drug management is considered moderate risk, as you can see on my bedside E/M reference card detailed below. Here is another clinical progress note example of appropriate documentation for a CPT® 99214:
I think it's always a good habit to include at least on ICD code in your note documentation, even though it's not technically required for established patient clinic follow-up visits that can achieve compliance with history and physical elements alone. Remember, the highest supported level of documentation for 2 out of 3 from history, physical and medical decision making on established clinic patients determines the overall level of CPT® code service. For history, four elements of the HPI (character, onset, location, duration, what makes it better or worse etc...) or documentation of the status of three chronic medical conditions PLUS at least 2-9 additional review of systems in addition to inquiry about the HPI related problem PLUS at least one element of past medical, family, or social history is required for this level four progress note. For physical exam, using 1997 E/M guidelines, documentation of 12 bullets from at least two organ systems or body areas is required. Remember, documentation of three vital signs can count as one bullet element. Here is another clinical example of a SOAP note for a CPT® 99214 established patient clinic visit:
S) Cough resolved; No SOB; No CP (2-9 ROS). Stopped taking lisinopril due to cough (one element from past medical history)O) 120/80 80 Tmax 98.9 (three vital signs = one bullet) alert, NAD, no icterus, no JVD, abdomen no masses; no palpable organomegally; lungs clear, normal chest wall motion; heart no murmur, regular rhythm; legs no edema, symmetric size; skin no rash or cyanosis, fingernails normal (at least 12 total bullets from two or more areas)A) HTN-stable, no changes planned.DM-stable, no changes planned.COPD-stable, no changes planned. (the status of three chronic medical conditions in place of HPI)P) Start ARB instead due to ACE cough.
S) Here for routine f/u visit. No CP/SOB/N/V/HA (at least 2 additional ROS). Still a nonsmoker (one element from social history).O) 120/80 80 Tmax 98.9 (three vital signs = one bullet).A) 1) HTN, controlled 2) DM II, controlled 3) CAD, controlled (three points on MDM for diagnosis and substituting three chronic medical conditions for HPI)P) Nothing needed.
According to the guidelines E/M risk table guidelines linked above, documenting the status of two stable chronic medical conditions qualifies as moderate risk in the medical decision making process. I have documented the status of three chronic medical conditions and that meets the minimum CPT® 99214 moderate medical decision making criteria using diagnosis (3 points) and risk (moderate). This qualifies for moderate risk in the risk table based on their qualifying description as "two or more stable chronic medical illnesses". I have meet my 99214 note requirements for 2 out of 3 areas from history, physical and MDM by meeting minimum criteria for history and MDM. This note is short and to the point. Some docs may think it's "too short" to be a CPT 99214. But, documentation is about content not quantity. It meets all minimum criteria for a mid-high level outpatient established office patient encounter based on the evaluation and management rules we have been given. Also remember, reasonable and necessary is always part of any evaluation, as is the requirement for the visit to be face-to-face in nature.
The complicated table of risk, one of the elements used to determine overall complexity in medical decision making, can be reviewed once again on page 37. What I have on my quick reference E/M card below only represents examples of moderate and high risk elements due to space limitations. At least for the hospitalist population (as a consultant on observation status scenarios), most established outpatient coding decisions will not be determined based on low risk medical decision complexity. I rarely use low risk in the table for any progress note because I'm just not smart enough to memorize it. I generally only use the table of risk when determining moderate and high risk encounters. In addition, most of my patients in the hospital present with moderate or high risk complexity. However, I have linked to it on page 37 above for your quick reference (and print it and post it in your office) should you desire a more detailed understanding. Here is another clinical example that meets minimum documentation requirements for a CPT® 99214:
S) HA present 4/10, global pain for 3 days and constant. No ringing in the ears (at least 4 HPI). No nausea/vomiting. No chest pain or SOB (at least 2 additional ROS). No FH brain cancer (one element family history).O) NothingA) Acute HA, stable. (one new problem with more work up planned and of uncertain prognosis 4 points on MDM for diagnosis and moderate risk too)P) Check CBC/BMP. OTC IBU for now. (consistent with 4 points on diagnosis for more workup planned)
That's all you need folks. Documentation of 2 out of 3 areas at their defined minimum requirements. That means 4 HPI, at least 2 additional ROS and one element from family history. Documentation of one new problem with more workup planned gets 4 points in the diagnosis portion of medical decision making. Note, this is more than the required 3 points for moderate complexity. The data portion is straightforward to low with only lab being drawn. The risk table is moderate risk due to an "undiagnosed new problem with uncertain prognosis". In this situation overall MDM is moderate even though no two MDM components are moderate levels. Remember, overall MDM is determined by the highest two out of three for diagnosis, data and risk. In this example, one of each exists. Therefore, the overall medical decision making is the highest two out of three, or moderate medical decision making. This is progress note is an example of a level four CPT® 99214 established outpatient clinic visit based on history and medical decision making complexity. Notice the volume of documentation matters much less than the quality of what is written to support the E/M charge appropriate for the visit.
In my discussions above, I have detailed several examples of the minimum documentation required to meet compliance for a level four established patient clinic visit. When would a hospitalist bill an established patient clinic procedure code in the hospital setting?
The CPT® medical billing code group 99211-99215 should used by hospitalists and other physicians or non-physician practitioners in the hospital setting under certain circumstances. I have previously discussed all the possible admission codes that could be used in the hospital setting. These established patient clinic and other outpatient visit codes are included as possibilities. I have provided a detailed discussion of that decision tree analysis at the link provided just above. However, I will discuss the pertinent portions of that analysis here.
For patients admitted observation status, the attending physician should choose from the observation group of medical codes 99218-99220 for the initial encounter, 99224-99226 for observation status follow-up codes, and 99217 for observation discharge. Under certain situations, same day admit and discharge billing codes 99234-99236 or critical care procedure codes may also apply too. This is not the case for consultants taking care of observation status patients. What codes should a consultant use in an observation status situation? This is where the correct code decision can get very complicated. Medicare no longer recognizes consult procedure codes. Consultants should pick the appropriate level of service from the established outpatient clinic code group 99211-99215 as their initial encounter and for all subsequent care visits (including the day of discharge) IF the patient has been seen previously by the physician or a physician partner of theirs in the same group and exact same specialty within the previous three years, unless documentation supports the use of critical care codes or until the patient becomes inpatient status.
If the patient has not been seen in the last three years by the same physician or partner physician in the same group and exact same specialty and subspecialty,, the consultant should use the new patient clinic code group 99201-99205 on their initial date of service and then choose a code from the established outpatient code group 99211-99215 for all subsequent observation services, including the day of discharge. Remember, all hospital observation CPT® code groups are reserved only for the attending physician.
The above discussion relates to Medicare because Medicare does not accept consult codes. Other insurances may still accept consultation codes. In that case, the consultant should chose a level of service from medical code group 99241-99245 (outpatient consult codes) as the initial encounter and then pick a billing code from the established patient clinic codes 99211-99215 for all subsequent care visits, including the day of discharge, while the patient is hospitalized for observation services. If the patient is formally admitted inpatient, the consultant should use the inpatient subsequent care codes 99231-99233 for all subsequent face-to-face encounters.
In my discussions above, I have detailed several examples of the minimum documentation required to meet compliance for a level four established patient clinic visit. When would a hospitalist bill an established patient clinic procedure code in the hospital setting?
USING ESTABLISHED PATIENT CLINIC CODES IN THE HOSPITAL SETTING
The CPT® medical billing code group 99211-99215 should used by hospitalists and other physicians or non-physician practitioners in the hospital setting under certain circumstances. I have previously discussed all the possible admission codes that could be used in the hospital setting. These established patient clinic and other outpatient visit codes are included as possibilities. I have provided a detailed discussion of that decision tree analysis at the link provided just above. However, I will discuss the pertinent portions of that analysis here.
For patients admitted observation status, the attending physician should choose from the observation group of medical codes 99218-99220 for the initial encounter, 99224-99226 for observation status follow-up codes, and 99217 for observation discharge. Under certain situations, same day admit and discharge billing codes 99234-99236 or critical care procedure codes may also apply too. This is not the case for consultants taking care of observation status patients. What codes should a consultant use in an observation status situation? This is where the correct code decision can get very complicated. Medicare no longer recognizes consult procedure codes. Consultants should pick the appropriate level of service from the established outpatient clinic code group 99211-99215 as their initial encounter and for all subsequent care visits (including the day of discharge) IF the patient has been seen previously by the physician or a physician partner of theirs in the same group and exact same specialty within the previous three years, unless documentation supports the use of critical care codes or until the patient becomes inpatient status.
If the patient has not been seen in the last three years by the same physician or partner physician in the same group and exact same specialty and subspecialty,, the consultant should use the new patient clinic code group 99201-99205 on their initial date of service and then choose a code from the established outpatient code group 99211-99215 for all subsequent observation services, including the day of discharge. Remember, all hospital observation CPT® code groups are reserved only for the attending physician.
The above discussion relates to Medicare because Medicare does not accept consult codes. Other insurances may still accept consultation codes. In that case, the consultant should chose a level of service from medical code group 99241-99245 (outpatient consult codes) as the initial encounter and then pick a billing code from the established patient clinic codes 99211-99215 for all subsequent care visits, including the day of discharge, while the patient is hospitalized for observation services. If the patient is formally admitted inpatient, the consultant should use the inpatient subsequent care codes 99231-99233 for all subsequent face-to-face encounters.
DISTRIBUTION OF ESTABLISHED PATIENT CARE CODES
What is the distribution of CPT® code 99214 relative to other levels of service in this medical code group? The graph below was published in May, 2012 by the OIG in a report titled Coding Trends of Medicare Evaluation and Management Services. You can find these charts and graphs starting on page 9 of this link provided here. As you can see, between 2001 and 2010, the distribution of established patient office visits has shifted higher. The proportion of level four 99214 and level five 99215 reimbursements has increased by 15% and 2% respectively, while the proportion of level three 99213 services billed for payment has decreased by 8% between 2001 and 2010. On an absolute percentage basis, in 2010, CPT® code 99214 was being billed 36% of the time, up from 21% of the time ten years previously.
Here is data from the most recent 2011 CMS Part B National Procedure Summary Files data (2011 zip file) showing how many CPT® 99214 encounters were billed and the dollar value of their services for Part B Medicare. As you can see in the image below, E/M code 99214 was billed 81,310,974 times in 2011 with allowed charges of $8,175,639,964.48 and payments of $5,710,149,881.25.
RVU VALUE
How much money does a CPT® 99214 pay? That depends on what part of the country you live in and what insurance company you are billing. E/M procedure codes, like all CPT® billing codes, are paid in relative value units (RVUs). This complex RVU discussion has been had elsewhere on The Happy Hospitalist. For raw RVU values, a CPT® 99216 is worth 2.21 total RVUs for facility services and 3.02 total RVUs for non-facility. The work RVU for 99214 is valued at 1.50. A complete list of RVU values on common hospitalist E/M codes is provided at the attached URL. What is the Medicare reimbursement for CPT® code 99216? In my state, a CPT® 99214 pays about $74 (facility) and $101 (non-facility) in 2016. The dollar conversion factor for one RVU in 2014 is $35.8043.
My coding card taught me that I should be billing for the work I'm providing and it has taught me how to document appropriately. You can see many more of my E/M lectures by clicking through to the link provided here. If you need bedside help determining what level of care you have provided, I recommend reviewing the pocket card described below.
LINK TO E/M CARD POST
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