One of the most confounding aspects of evaluation and management (E/M) coding is the distinction between a 99213 and a 99214 established patient office visit.
These visits must meet two of three key components listed below:
History |
Exam |
Medical decision making | |
---|---|---|---|
99213 key components | Expanded problem focused | Expanded problem focused |
Low |
99214 key components | Detailed |
Detailed |
Moderate |
Note: Alternatively, if more than half the visit involves counseling or coordination of care, the visit may be reported based on time.
The following tips can help you recognize when a visit meets the requirements of a 99214, as opposed to a 99213.
1. Remember 4, 2, 1 for a detailed history.
2. Pick a method for documenting a detailed exam.
3. Think in threes for moderate decision making.
The Centers for Medicare & Medicaid Services recently proposed significant changes to the E/M documentation guidelines. Read the AAFP's initial comments on the proposed rule.
Adapted from “99213 or 99214? Three Tips for Navigating the Coding Conundrum.”
Disclaimer: The opinions and views expressed here are those of the authors and do not necessarily represent or reflect the opinions and views of the American Academy of Family Physicians. This blog is not intended to provide medical, financial, or legal advice. All comments are moderated and will be removed if they violate our Terms of Use.