CPT code 99214 is the fourth of the five office or outpatient visit levels for an established patient. It fits when the visit involves a moderate level of medical decision making (MDM), or when the practitioner's total time on the date of the visit meets the time CPT sets for 99214. Either route is enough; the practitioner picks the one that the record supports better. A visit that meets neither belongs at a lower level, and one that meets the high level belongs at 99215.
These rules come from the AMA's CPT office visit guidelines, which took effect in 2021, and Medicare follows them for level selection. Other payers generally use the same CPT guidelines but may add their own documentation or claim-review policies, so check the payer's policy for the date of service. Payment amounts vary by payer and locality and aren't covered here; for Medicare, use the Physician Fee Schedule look-up.
Who counts as an established patient?
For Medicare, a patient is established if they received a professional service from the practitioner, or from another physician of the same specialty in the same group practice, within the previous three years. CPT uses the same three-year window and says "exact same specialty and subspecialty". If no one in that specialty in the group has seen the patient in three years, the visit is a new patient visit (99202 to 99205), not 99214. The 99203 guide covers the new patient rules in detail.
How is the visit level chosen?
Since 2021, office visit levels are chosen in one of two ways:
- Medical decision making. The level of MDM on the visit (straightforward, low, moderate or high).
- Total time. The practitioner's total time on the date of the visit.
History and examination still have to be performed and documented as medically appropriate, but CMS says they no longer affect which level is chosen. Medicare also says the volume of documentation shouldn't decide the level, and that it isn't medically necessary to bill a higher level when a lower one is warranted.
What does moderate medical decision making mean?
CPT defines MDM with three elements:
- Problems addressed: the number and complexity of the problems the practitioner addressed at the visit.
- Data: the amount and complexity of data reviewed and analyzed, such as external notes, test results, tests ordered, an independent historian, independent interpretation of a test, or a discussion of management with an external physician.
- Risk: the risk of complications, morbidity or mortality from the management decisions made at the visit.
To reach a level of MDM, two of the three elements must meet or exceed that level. For 99214, that means two of the three at moderate. In the AMA's table, a chronic illness that is getting worse, or two or more stable chronic illnesses, are examples of moderate problems, and prescription drug management is one of the examples of moderate risk. Use the full table in the CPT code set or the AMA's published guidelines rather than a summary: each element has its own definitions, and "problems addressed" means problems the practitioner actually managed or evaluated at the visit, not every diagnosis on the problem list.
How does time-based coding work for 99214?
When time is used, it's the total time the physician or other qualified health care professional personally spends on the patient's care on the date of the visit. It includes face-to-face and non-face-to-face work, such as reviewing tests before the visit, examining and counseling the patient, ordering tests or drugs, documenting in the record and coordinating care that isn't separately reported. It doesn't include time spent by clinical staff, time on other services that are billed separately, or travel.
The minimum time for 99214 is set in the CPT code descriptor. Use the CPT code set in effect on the date of service rather than a number copied from an older article. Medicare adds two rules:
- The full time must be met. The general CPT rule that lets some timed services count once the midpoint is passed doesn't apply to office visit levels.
- The record must show the time, either as start and stop times or as the total time.
Prolonged office visit time is reported to Medicare with HCPCS code G2212, and only with 99205 or 99215 when the level is chosen by time. It is never added to 99214.
99214 or 99213?
The difference is the level of MDM (low for 99213, moderate for 99214) or the total time. Two points trip up practices:
- Undercoding is an error too. Choosing 99213 by habit when the record documents moderate MDM misstates the visit just as coding 99214 without support does.
- Count what was addressed, not what is listed. A long problem list, a long note or a cloned exam doesn't raise the level. The note should show which problems were managed, what data were reviewed and why, and what decisions were made.
What does Medicare's G2211 add-on have to do with 99214?
HCPCS code G2211 is a Medicare add-on code that can be reported with any office visit level, including 99214, when the practitioner is the continuing focal point for the patient's care or provides ongoing care for a single serious or complex condition. CMS says the complexity it pays for is in that longitudinal relationship, not in the clinical condition, so it has nothing to do with choosing between 99213 and 99214. Medicare doesn't pay G2211 when the visit carries modifier 25, except when the visit is on the same day as an annual wellness visit, a vaccine administration or a Part B preventive service. In the CY 2027 Physician Fee Schedule proposed rule (July 2026), CMS proposes replacing G2211 with a modifier on the visit code; check the final rule before January 2027.
What should the note show?
For MDM-based selection:
- the problems addressed and their status, such as stable, worsening or new with an uncertain outcome
- the data reviewed or ordered, and any independent interpretation or discussion with another clinician
- the management decisions and the risks weighed, including options considered but not chosen
For time-based selection:
- the total time on the date of the visit, or start and stop times
- enough about the activities to show the time was the practitioner's, not clinical staff time
In every case, the diagnosis codes on the claim should match what the note says was addressed. See CPT vs ICD-10 codes for how the two code sets fit together on a claim.
What about a procedure on the same day?
A visit on the same day as a minor procedure is part of the procedure unless it is a significant, separately identifiable service, reported with modifier 25 when the record supports it. The decision to perform the minor procedure is not, on its own, a separate visit. The CO-97 guide explains how same-day visits get bundled and when modifier 25 applies.
How do practices keep 99214 accurate?
- Analyze a sample of visits at every level, not only 99214 and 99215, and check both directions.
- Compare each provider's spread of visit levels with the documentation, not with a target distribution.
- Train on the current CPT MDM definitions and the payer's documentation rules, and update templates so they don't generate cloned text.
Highview bills office visits and other professional services through its physician billing service.
Sources
- CMS, Evaluation and Management Services Guide, MLN006764 (May 2026): new and established patients, level selection by MDM or time, time documentation, G2211 and modifier 25, G2212.
- CMS, Medicare Claims Processing Manual, Chapter 12, sections 30.6.1 (selection of level of E/M service) and 30.6.7 (office visits, G2211).
- AMA, CPT E/M office or other outpatient services and prolonged services code and guideline changes (effective January 1, 2021): the three MDM elements, the two-of-three rule, the MDM table, what counts toward total time, new and established patients.
- AMA, CPT Evaluation and Management: background to the 2021 and 2023 E/M revisions.
- CMS, Medicare NCCI Add-on Code Edits (effective October 1, 2026): base codes for G2211 and G2212.
- CMS, CY 2027 Physician Fee Schedule proposed rule fact sheet: proposed change to G2211.
- CMS, Search the Physician Fee Schedule.