99213 versus 99214: Are You Coding Correctly or Shortchanging Yourself?

Posted 09/16/18 by Ricky Bass and filed under:
99213 vs. 99214

I have seen data that shows 99213 is the most common diagnosis code used by primary care physicians representing about 55% of codes in a practice. 99214s represent just over 30% of codes. I suspect this still to be the case as my percentages are closer 60% 99214 and 30% 99213 and I recently received a communication from an insurer pointing this out to me.

They were implying that I was potentially over coding compared to physicians similar to me. However, I believe that many of the physicians in the panel I was compared to are undercoding. Having routinely passed billing audits over the last 15 years, I am confident that my billing and coding are solid and the letter was nothing more than the insurer trying to get me to second guess my practices.

Previous research looking at expert coders evaluation of family medicine physicians found that as many as 30% of submitted 99213s could actually have been coded as a 99214.

Physicians today are often scared to bill too many 99214s. However, roughly 80% of encounters in a typical outpatient primary care clinic will involve deciding between a level 3 or 4 return visit. The most common underbilling in primary care is coding a 99213 for what could be billed a 99214

What could this be costing you?

In my region the difference in Medicare reimbursement between a 99213 and 99214 is approximately $35. If you see 20 patients per day and are undercoding 30% or 6 of those patients, you are decreasing your reimbursement by $210 a day or $9,240 per day over a 44 week year.

For private insurers the delta between the 99213 and 99214 can be even greater leading to more money lost.

In order to bill for a followup 99214 for an established patient, the physician must provide 2 of 3 of the following components:

  • a detailed history
  • a detailed physical exam
  • medical decision making (MDM) of moderate complexity

If you have a detailed history and moderate MDM then you will not even need to count your physical exam points.

The key is knowing if you meet moderate MDM!

To meet moderate MDM, your documentation must achieve at least 2 of the 3 criteria: 1) 3 problem points or higher; 2) 3 data points or higher; and 3) be listed under moderate risk in the risk table. See the link to a previous article I wrote on medical decision making.

When should you be thinking 99214

Think 99214 in any of the following situations:

  • If the patient has a new complaint with a potential for significant morbidity if untreated or misdiagnosed.
  • If the patient has three or more old problems that require prescription medication management.
  • If the patient has a new problem that requires a prescription, ordering lab, X-ray or specialty consult.
  • If the patient has one stable problem and one inadequately controlled problem that requires medication refills or adjustments.
  • If you spend at least 25 minutes face to face with a patient and more than half the time involves counseling or coordination of care, you can code 99214 based on time.
  • An acute complicated injury.

What is prescription drug management?

“Prescription drug management” is based on documented evidence that the provider has evaluated medications as part of a service, in relation to the patient. This may be a prescription being written or discontinued, or a decision to maintain a current medication/dosage. Reviewing and confirming the patient’s existing medication regimen also meets this definition.

Note: Simply listing current medications is not considered “prescription drug management.”

If you are proving prescription drug management than you will automatically meet moderate risk.

What constitutes a detailed history? Remember the 4,2,1

A detailed history requires:

  • 4 elements of the history of present illness (HPI)
  • Review of 2 organ systems in review of systems (ROS)
  • 1 one element of the past, family, and social history (PFSH)


Documenting the status of 3 or more chronic medical conditions is how I often meet the requirement. If not you will need to document 4 or more elements. The elements include:

  • location
  • quality
  • severity
  • duration
  • timing
  • context
  • modifying factors
  • associated signs and symptoms


In order to bill a 99214 you need to address the organ system of the chief complaint and at least one other.


The PFSH elements must be reviewed or updated by you and they must relevant to a condition you address at the current visit. It has been my practice to start every visit with the patient’s smoking status (e.g. 34 y.o. Non-smoking or smoking M/F…). Because smoking is pertinent to nearly everything I do in primary care

What is a detailed exam? Think 4X4

With the “4×4” method, documenting four exam items of in four different body areas/organ system will lead to documentation for a 99214. If you document less than this, you exam will most likely be compatible with an expanded problem-focused exam consistent with a 99213.

Join my 4 week billing and coding course

Join me for a 4 week billing and coding course where I will teach you how to better navigate billing and coding so that you can get all the 99214s you deserve.

You should be paid for all the work you do. Just because you have become efficient does not mean you should be paid less. We will go over all of the components in much greater detail as well as looking for patterns that you can easily identify in your own practice.

In this 4 week live course you will learn the most common billing mistakes and pitfalls as well as documentation tips to make you more efficient.