99213 vs 99214 CPT Code: Key Differences and Documentation
CPT codes 99213 and 99214 are used for established patient office visits and mainly differ based on medical decision-making (MDM) complexity and visit time. Code 99213 applies to lower-complexity visits involving stable chronic conditions or minor issues, typically lasting 20–29 minutes. In contrast, 99214 is used for more complex visits with multiple or worsening conditions, additional data review such as labs or imaging, moderate risk, and longer encounter times of 30–39 minutes, reflecting a more detailed clinical evaluation.
Choosing between CPT codes 99213 and 99214 depends on the patient’s condition, the amount of data reviewed, and overall risk involved in the visit. Accurate documentation of time, assessment, and decision-making is essential, as undercoding can reduce reimbursement while overcoding may trigger audits.
CPT codes 99213 and 99214 are Evaluation and Management (E/M) codes used for outpatient visits with established patients.
The primary difference between these two codes is based on the complexity of medical decision making (MDM), total time spent during the encounter, and the level of documentation required.
99213 (Level 3 E/M Visit)
- Used for low-complexity office visits
- CPT 99213 requires 20-29 minutes of total time spent with the patient
- Involves a problem-focused history and examination
99214 (Level 4 E/M Visit)
- Used for moderate-complexity office visits
- Requires 30–39 minutes of total time spent on the date of service
- Involves a more detailed history and a comprehensive examination
- Selecting the correct CPT code helps ensure accurate billing, proper reimbursement, and reduced compliance risks.
Key Differences Between CPT 99213 and 99214
A simple way to determine when to use 99213 vs 99214 is by evaluating the visit complexity and total time required.
| Feature | 99213 (Level 3) | 99214 (Level 4) |
|---|---|---|
| Medical Decision-Making (MDM) | Low complexity | Moderate complexity |
| Total Time Spent | 20–29 minutes | 30–39 minutes |
| Number of Diagnoses | 1–2 stable conditions | Multiple or new problems |
| Data Review | Minimal or none | Labs, imaging, or external records |
| Risk of Complications | Low | Moderate |
For example, a patient with a stable chronic condition, such as controlled hypertension, typically qualifies for 99213.
A patient with a new diagnosis or worsening condition that requires medication adjustments or additional evaluation is more likely to qualify for 99214.
How Documentation Impacts 99213 vs 99214
Accurate documentation is essential to support the correct use of CPT codes 99213 and 99214.
History and Examination
- 99213: Problem-focused history and examination
- 99214: Detailed history and comprehensive examination
Medical Decision-Making (MDM) Complexity
- 99213: Straightforward or low complexity
- 99214: Moderate complexity involving multiple diagnoses, treatment changes, or data analysis
Time-Based Coding
When MDM requirements are not fully met, providers may still bill based on total time spent on the encounter:
- 99213: 20–29 minutes
- 99214: 30–39 minutes
If a significant portion of the visit is spent on counseling or care coordination, time-based coding may be the most appropriate option.
How Medical Decision-Making (;MDM) Determines Your Code
The most important factor when choosing between 99213 and 99214 is the level of medical decision-making (MDM).
MDM is based on three key elements:
- Number and complexity of problems addressed
- Amount and complexity of data reviewed
- Risk of complications, morbidity, or mortality
For example, a visit that includes reviewing lab results and discussing new treatment options for a worsening condition typically supports 99214. A routine follow-up visit with no changes to treatment is more appropriately billed as 99213.
Common Billing Mistakes and How to Avoid Them
Underbilling (Using 99213 When 99214 Is Justified)
- Incomplete documentation of MDM
- Failing to capture total time spent on patient care
- Omitting data reviews, medication changes, or lab discussions
Overbilling (Using 99214 When 99213 Is Appropriate)
- Insufficient documentation to support moderate complexity
- Overstating risk levels or data complexity
- Misunderstanding time-based coding requirements
To minimize errors, ensure that all E/M documentation clearly supports the selected CPT code.
Why Proper Coding Matters for Reimbursements
Using the correct CPT code is critical for:
- Maximizing reimbursements without triggering audits
- Reducing claim denials and improving payment timelines
- Maintaining compliance with CMS and AMA guidelines
At Medmax RCM, we help practices avoid costly coding errors and optimize medical billing to strengthen revenue cycle management.
Get Expert Billing Support with Medmax
Choosing the right CPT code between 99213 vs 99214 doesn’t have to be complicated. With proper documentation, accurate MDM assessment, and effective time tracking, your practice can prevent revenue loss and ensure compliant coding.
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- Use our Global Period Calculator to track coding timelines
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Frequently Asked Questions (FAQs)
What is cpt code 99214?
CPT code 99214 signifies a Level 4 office or outpatient visit for an established patient, requiring a detailed history, a detailed examination, and medical decision-making of moderate complexity, or it can be based on 30-39 minutes of total time spent on the encounter.
What is cpt code 99213?
CPT code 99213 signifies an Established Patient Office/Outpatient Visit with low to moderate complexity, often a “Level 3” visit, involving 20-29 minutes of provider time (or appropriate medical decision-making), focusing on managing stable chronic conditions or minor issues, requiring a problem-focused history/exam, and ensuring proper documentation for billing.
What Is the Difference Between CPT 99213 and 99214?
CPT 99213 and 99214 are Evaluation and Management (E/M) codes used for outpatient visits with established patients. The primary difference lies in the complexity of medical decision-making (MDM) and the total time spent during the encounter.
CPT 99213 applies to low-complexity visits requiring 20–29 minutes, while CPT 99214 is used for moderate-complexity visits requiring 30–39 minutes, along with more detailed history, examination, and data review.
When Should I Use 99213?
Use CPT 99213 when the patient visit involves low-complexity medical decision-making. This typically includes one or two stable conditions, minimal or no diagnostic testing, and a low risk of complications. The total time spent on the encounter, including face-to-face care and documentation, should fall between 20–29 minutes.
What Is the Criteria for a 99214?
To bill CPT 99214, the visit must meet moderate-complexity MDM requirements. This may involve managing multiple diagnoses, reviewing laboratory results or imaging, initiating or adjusting medications, or discussing treatment options that carry moderate risk.
The total time spent on the date of service must be 30–39 minutes, which can include counseling, care coordination, and documentation.
What Is Modifier 55?
Modifier 55 (Postoperative Management Only) is used when a physician or qualified healthcare professional provides only the postoperative care following a surgical procedure. This modifier indicates that another provider performed the surgery, while the reporting provider managed the post-operative care during the global period.
How to Add Modifier 25?
Modifier 25 (Significant, Separately Identifiable E/M Service) is appended to an E/M code when a provider performs a separate and distinct evaluation and management service on the same day as another procedure.
To use modifier 25, documentation must clearly show that the E/M service was medically necessary and unrelated to the procedure performed. When submitting the claim, append modifier 25 to the E/M code (for example, 99213-25 or 99214-25) to indicate the additional service.
