99213 vs. 99214: Three tips for spotting the difference

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:

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.

• Four elements of the history of present illness (HPI),
• Two organ systems in the review of systems (ROS),
• One element of the past, family, and social history (PFSH).
  
  These elements are in addition to the chief complaint, unless the visit is preventive and has none.

2. Pick a method for documenting a detailed exam.

• The 12 bullet point method: Document at least 12 bullet points — whether normal or abnormal. (See the full list of bullet points on page 13 of the guidelines.)
• The 5-7 method: Document findings in five to seven organ systems or body areas. At least one system should be in detail, but the rest can be in brief.
• The 4x4 method: Document four items of exam in four different body areas/organ systems.

3. Think in threes for moderate decision making.

• Three points for diagnoses or management options (e.g., three points for a new problem with no additional work-up planned),
• Three points for data reviewed (e.g., one point for reviewing labs and two points for reviewing old records),
• Three options for moderate risk. The risk component doesn’t have points assigned to it, but here’s what to look for: a presenting problem such as a chronic condition with mild exacerbation, a diagnostic procedure such as a stress test, or a management option such as prescription drug management.
  
  Only two of the three would be required 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.”