CPT 99214: Office Visit for Established Patient, Moderate Complexity

CPT 99214 – Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making (MDM).

Key Criteria (2021+ MDM-Based Framework)

• MDM: Moderate – Meets 2 of 3:
  • Number/complexity of problems addressed: ≥2 stable chronic, 1 acute uncomplicated, or 1 acute with systemic symptoms.
  • Data reviewed/analyzed: ≥3 points (labs, imaging, notes, independent historian, discussion of management).
  • Risk: Moderate (prescription drug management, minor surgery decision).
• Time (if time-based) – 30–39 min total time on date of encounter.

Typical Clinical Scenarios

• Follow-up for 2–3 controlled chronic conditions (HTN, DM, lipids) with medication adjustment.
• New acute problem (e.g., UTI, bronchitis) requiring Rx + labs.
• Chronic disease with mild exacerbation.

Documentation Must-Haves

• History: HPI (2+ elements), ROS (1 system), PFSH (1 area) – or “interval history” if appropriate.
• Exam: Focused or expanded problem-focused.
• MDM: Explicit assessment of problems, data, risk.
• Time statement if billing by time.

99214 is the most commonly billed established-patient visit; accurate MDM documentation is critical for audit defense.