The short answer
99213 and 99214 are both office visits for an established patient. 99213 fits a visit of low complexity; 99214 fits moderate complexity. Complexity is judged on three things: the problems handled, the data looked at, and the risk of the plan. Two of the three must reach the level. A visit can also be leveled on the provider's total time that day: 20 minutes or more for 99213, 30 minutes or more for 99214.
What separates 99213 from 99214
| Element | Usually 99213 | Usually 99214 |
|---|---|---|
| Problems addressed | One new, simple illness or injury; one chronic condition that is stable; or a couple of minor issues. | A chronic condition that is worsening or causing side effects; two or more chronic conditions managed together; a new problem whose cause isn't settled; or an acute illness affecting the whole body. |
| Data reviewed | A little: a couple of tests or outside notes, or history taken from a caregiver. | More: several tests or records together, reading a test yourself, or talking the plan through with a clinician outside the practice. |
| Risk of the plan | Low-risk care, such as over-the-counter medicine. | Prescription drug management, or treatment shaped by social factors such as cost or access. |
The two-of-three rule
The level is the highest one that two elements reach together. One strong element is not enough: a visit with moderate risk but simple problems and little data stays a 99213. Two elements at moderate make it a 99214, whatever the third one shows.
Does a prescription make it a 99214?
Not on its own. Managing a prescription puts risk at moderate, but that is one element. A simple infection treated with an antibiotic is usually a 99213. If the same visit also manages a second, ongoing condition, problems can reach moderate too, and the visit becomes a 99214.
Do two stable chronic conditions make it a 99214?
Often. Two stable chronic conditions, both assessed at the visit, put problems at moderate. If the plan manages their prescriptions, risk is moderate as well, and the visit supports 99214. Conditions that are only listed, or followed by another clinician without being assessed today, don't count.
99213 vs 99214 by time
Time is the provider's total time on the date of the visit, including review before it and documentation after it. Staff time and separately billed services don't count. 20 minutes or more supports 99213, 30 minutes or more supports 99214, and from 40 minutes the visit moves to 99215. Write the total in the note, and check your payer's policy.
Before you bill 99214
- At least two of problems, data and risk reach moderate.
- Every problem you count was assessed or treated in this note, not just listed.
- If you bill on time, the total time is written down and is 30 minutes or more.
- The assessment and plan show the reasoning, not only a list of diagnoses.
Have a note in front of you? Paste a de-identified note into the free calculator and see the level with each element's reasoning.
Check a note's level99213 and 99214 questions
Is 99214 for new or established patients?
Established patients only. The new-patient visits at the same complexity are 99203 (low) and 99204 (moderate).
Do history and exam still decide the level?
No. Since 2021, history and exam only need to be medically appropriate. The level comes from medical decision making or total time.
Can I level on time instead of medical decision making?
Yes. Use whichever the note supports better. For time, count the provider's own time on the date of the visit, before, during and after it, and write the total in the note.
How much more does 99214 pay than 99213?
It depends on the payer, your location and your contract. Check your fee schedule rather than a national average.
Does billing a lot of 99214 visits invite audits?
Payers compare each provider's mix of levels with their peers. A high share of 99214 is fine when the notes support it, but it is where reviews tend to start.
Related: E/M coding guidelines, explained, every MDM level combination and how we automate E/M leveling.
Written in our own words for education, not as coding or billing advice. For the authoritative definitions, see the current AMA CPT® code set and your payers' policies. CPT® is a registered trademark of the American Medical Association.