Think 99214 if you see these problems or procedures

A 99214 requires two of three key components: a detailed history, a detailed exam, or moderate medical decision making. Some payers require that medical decision making be one of the two key components because it drives medical necessity.

Moderate medical decision making, in turn, requires two of three components: diagnoses or management options (three points), data reviewed (three points), or moderate risk.

Because the risk component doesn’t have points assigned to it, it is more subjective and difficult to identify, but here’s what to look for in moderate risk consistent with a 99214:

• A presenting problem such as a chronic condition with mild exacerbation, side effects, or inadequate response to treatment; two or more stable chronic conditions; an acute illness with systemic symptoms; an acute complicated injury; or an undiagnosed new problem with uncertain prognosis.
• A diagnostic procedure ordered such as a stress test, diagnostic endoscopy without risk factors, or a deep needle or incisional biopsy.
• A management option selected such as prescription drug management, which could include prescribing a new medication, changing existing medications, or reviewing and confirming the patient’s existing medication regimen. Other examples include minor surgery with identified risk factors, intravenous fluids with additives, and closed treatment of fracture or dislocation without manipulation.

Read the full FPM article: “99213 or 99214? Three Tips for Navigating the Coding Conundrum.”