CPT Code 99214 Explained with Examples

Knowing when and how to use CPT code 99214 is crucial for receiving accurate payments and maintaining compliance with current documentation guidelines. As patient care becomes more complex and documentation standards continue to evolve, it is more important than ever for providers to choose the right codes, especially for visits that go beyond basic check-ups. Whether you are treating chronic conditions, making moderate-risk medical decisions, or spending extended time with patients, CPT 99214 allows you to capture the actual value of your clinical work, provided it is used correctly. This blog will walk you through everything you need to know about CPT Code 99214.

What is CPT Code 99214?

CPT Code 99214 is a billing code used to represent a Level 4 evaluation and management (E/M) service for established patients in an office or outpatient setting. It is applicable when the patient's condition requires a moderate level of medical decision-making or when the provider spends 30 to 39 minutes in total on the date of the visit, with more than 50% of the time spent on counselling or care coordination.

This code identifies visits that are more complex than routine check-ups and include thorough assessments, management plans, or extensive counselling.

When to Use CPT Code 99214

CPT code 99214 should be applied when both medical necessity and supporting documentation meet the following requirements:

• Detailed History and Examination

The patient visit should include a comprehensive review of the patient's past medical history, family history, and a physical examination that assesses multiple organ systems or body areas.

A patient returns to the provider for a follow-up related to chronic migraines. The provider performs a thorough neurological examination, updates the patient's family history regarding stroke, and reviews any social stressors that may be contributing to the patient's symptoms. This level of detail qualifies as a detailed history and examination.

• Medical Decision Making (MDM)

The MDM must involve moderate complexity. This is assessed by the number and complexity of problems, the amount and type of data reviewed (including laboratory results, imaging studies, and prior medical notes), and the risk of complications or morbidity.

A provider evaluates a patient with worsening asthma and orders a chest X-ray and spirometry while adjusting the medication plan. This reflects moderate MDM due to the diagnostic workup, chronic condition management, and the risk associated with the treatment plan.

• Moderate Complexity

CPT 99214 is used when the patient's condition requires moderate evaluation and management. This typically involves multiple symptoms, chronic illnesses with potential exacerbation, or the initiation of prescription medications.

A patient with type 2 diabetes and high blood pressure needs lab review and medication changes. The provider initiates a new medication for blood pressure and offers lifestyle advice. Such a situation exhibits moderate complexity due to the presence of multiple conditions and care decisions.

• Time-Based Billing (Optional)

If the visit lasts 30–39 minutes, and more than 50% of that time is spent in counselling or coordinating care, the provider can use time-based billing for 99214. Documentation must include the total time and describe the content of counselling or coordination.

A provider spends 35 minutes with a patient who is struggling with anxiety and medication adherence. Additionally, a mental health provider spends more than 20 minutes of the visit addressing therapy choices, reviewing medication side effects, and coordinating aspects of care. If counselling makes up over half of the total face-to-face time, then billing the visit under CPT code 99214 based on time is appropriate.

Reimbursement Rates

Accurate coding and correct documentation directly influence reimbursement amounts for CPT code 99214. Here is what different payers typically reimburse in 2025:

• Medicare: Approximately $125.18 on average, though this rate may vary by geographic region.
• Medicaid: Around $68.97, depending on the specific reimbursement rates set by each state.
• Commercial Payers: Reimbursement rates vary based on payer contracts and are often comparable to or higher than those of Medicare.

Key Reimbursement Factors

• Payers may request evidence of moderate complexity in decision-making or total time spent.
• The visit must be medically necessary and clearly documented.
• Time-based billing must specify the total time and the counselling or coordination activities.

Important to Note: When billing for telehealth services, use Modifier 95 to indicate a virtual visit, along with the correct use of the place of service (POS).

2025 Updates to CPT 99214

The following are the several updates that affect how CPT code 99214 is used and reimbursed in 2025:

1. Medicare Conversion Factor Reduction: The conversion factor has decreased from $33.2875 to $32.3465, resulting in a slight reduction in payment rates.
2. Introduction of Add-On Code G2211: The G2211 code can now be billed in conjunction with 99214 to reflect the additional complexity in patient management. This is especially useful for patients with ongoing or severe chronic conditions.
3. Telehealth Coding Changes: The new CPT codes (98000–98016) introduced in 2025 separate audio-video and audio-only telehealth encounters. These replace previous telephone codes (99441–99443), allowing clearer billing pathways for remote care.
4. E/M Documentation Guideline Revisions: As of 2025, providers may choose the visit level based on either:

• Medical Decision Making (MDM), or
• Total time spent on the encounter date.

99214 corresponds to moderate complexity MDM or 30–39 minutes total time.

Common Mistakes When Reporting CPT 99214

Even experienced providers and coders can make reporting mistakes that result in reduced revenue or trigger audits. The most common pitfalls are as follows:

• Undercoding

Some providers choose a lower-level code like 99213 instead of 99214, even when the service delivered qualifies for a higher level. This often happens due to fear of audits or incomplete documentation.

• Confusion Over Documentation Rules

Billing CPT 99214 requires meeting specific documentation criteria—either through medical decision making (MDM) or time-based billing. If a provider fails to fully document the number of conditions addressed, diagnostic tests reviewed, or the time and nature of counselling, the claim may be denied.

• Outdated CPT Knowledge

Documentation and billing guidelines for CPT codes are subject to frequent changes, particularly following updates from the AMA or CMS. If providers or billing teams continue using outdated rules or templates, they risk claim rejections or non-compliance.

Best Billing Practices for CPT 99214

Strong billing practices lead to fewer denials, better compliance, and maximum reimbursement. You should implement the following strategies for coding CPT 99214 accurately:

• Use Proper Modifiers and POS Codes

When billing for telehealth services, use Modifier 95 to indicate a real-time audio-video interaction. It is equally important to submit the correct Place of Service (POS) code—whether the appointment took place in-office, via telehealth, or in a home care setting. Payers often check for these details before approving payment.

• Conduct Regular Internal Audits

Conducting internal audits helps uncover frequent issues, such as incomplete documentation, incorrect modifier use, or undercoding. These reviews enable you to address potential errors in advance, thereby reducing rejections and lowering the likelihood of payer audits.

• Outsource to 24/7 Medical Billing Services

If your practice is short on time or expertise, outsourcing E/M billing to 24/7 Medical Billing Services can result in accurate coding and improved financial outcomes. Our billing professionals provide assistance with coding compliance, audit readiness, and staying up-to-date with ongoing industry updates. With experience across multiple specialities and high-volume practices, we help providers catch missed codes, reduce denials, and improve overall collections.

Are you also facing the issue of frequent CPT 99214 errors? Is your revenue getting drained? If so, outsource your CPT 99214 billing to 24/7 Medical Billing Services today to reduce risks and boost returns.

FAQs

Q1. What types of providers commonly use CPT 99214?

Primary care physicians, internists, psychiatrists, and specialists frequently use 99214 for moderate complexity follow-up visits.

Q2. Is CPT 99214 only for managing chronic conditions?

It can also apply to new or worsening acute problems requiring moderate-level evaluation and decision-making.

Q3. Can nurse practitioners or PAs bill 99214?

As long as the visit meets the criteria and scope of practice, NPs and PAs can bill 99214.

Q4. Is there a global period for CPT 99214?

99214 is not associated with a global period; it's a standalone E/M service code.

Q5. What is the difference between CPT 99213 and 99214 in risk level?

CPT 99214 involves moderate risk, whereas 99213 involves low risk in terms of the complexity of data and patient management.