CPT Codes 99213 vs 99214: Understanding the Key Differences

CPT codes 99213 and 99214 are commonly used Evaluation and Management (E/M) codes for established patient office or outpatient visits. Both codes apply to follow-up encounters; however, they differ primarily based on medical decision-making (MDM) complexity, total time spent by the provider, and documentation requirements.

CPT 99213 is generally reported for lower-complexity visits, such as stable chronic conditions or minor complaints, and typically reflects 20–29 minutes of total provider time.

CPT 99214, in contrast, is used for more involved visits that may include multiple or worsening conditions, medication adjustments, review of labs or imaging, and moderate risk, with 30–39 minutes of total encounter time.

Selecting the appropriate code depends on the patient’s clinical status, the volume and complexity of data reviewed, and the overall level of risk. Thorough documentation is essential—undercoding can reduce revenue, while overcoding increases audit exposure.

What Are CPT Codes 99213 and 99214?

CPT codes 99213 and 99214 are E/M codes used to report outpatient visits for established patients. The key differences between them are determined by:

• The level of medical decision-making (MDM)

• Total time spent on the date of service

• The extent of documentation required

99213 vs 99214: Levels of Care Explained

CPT 99213 (Level 3 E/M Visit)

• Appropriate for low-complexity office visits

• Requires 20–29 minutes of total provider time

• Typically addresses one or two stable conditions

• Involves a problem-focused history and examination

CPT 99214 (Level 4 E/M Visit)

• Used for moderate-complexity office visits

• Requires 30–39 minutes of total provider time

• Involves multiple, new, or worsening conditions

• Requires a more detailed history and comprehensive examination

Accurate code selection supports proper reimbursement, billing compliance, and reduced audit risk.

Key Differences Between CPT 99213 and 99214

Feature	99213 (Level 3)	99214 (Level 4)
Medical Decision-Making	Low complexity	Moderate complexity
Total Time	20–29 minutes	30–39 minutes
Diagnoses	1–2 stable conditions	Multiple or new problems
Data Review	Minimal or none	Labs, imaging, external records
Risk Level	Low	Moderate

Example:

• A routine follow-up for well-controlled hypertension typically supports 99213.

• A visit involving medication changes, new symptoms, or lab interpretation is more appropriately reported as 99214.

How Documentation Impacts 99213 vs 99214

Complete and accurate documentation is critical to support the chosen E/M code.

History and Examination

• 99213: Problem-focused history and exam

• 99214: Detailed history and comprehensive exam

Medical Decision-Making (MDM)

• 99213: Straightforward or low complexity

• 99214: Moderate complexity involving multiple conditions, treatment changes, or data analysis

Time-Based Coding

When MDM criteria are not fully met, providers may code based on total time:

• 99213: 20–29 minutes

• 99214: 30–39 minutes

Time-based coding is particularly helpful when counseling or care coordination makes up most of the visit.

How MDM Determines the Correct CPT Code

Medical decision-making (MDM) is the primary factor when determining whether to bill 99213 or 99214. MDM is assessed based on:

• The number and complexity of problems addressed

• The amount and complexity of data reviewed

• The risk of complications, morbidity, or mortality

A simple follow-up without treatment changes typically supports 99213, while reviewing diagnostic results and modifying treatment for a worsening condition usually supports 99214.

Common Billing Errors to Avoid

Underbilling (Reporting 99213 Instead of 99214)

• Incomplete MDM documentation

• Failure to record total provider time

• Missing documentation of lab reviews or medication changes

Overbilling (Reporting 99214 Instead of 99213)

• Insufficient documentation to support moderate complexity

• Overstating risk or data reviewed

• Misapplication of time-based coding guidelines

Clear, detailed documentation helps prevent denials, audits, and compliance issues.

Why Accurate CPT Coding Is Important

Correct CPT code selection helps medical practices:

• Optimize reimbursement while minimizing audit risk

• Reduce claim denials and payment delays

• Maintain compliance with CMS and AMA guidelines

At MedMax RCM, we assist healthcare providers in avoiding coding mistakes and improving overall revenue cycle performance.

Get Professional Billing Support with MedMax RCM

Deciding between 99213 vs 99214 doesn’t have to be complicated. With proper documentation, accurate MDM evaluation, and precise time tracking, your practice can avoid revenue loss and remain compliant.

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Frequently Asked Questions (FAQs)

What is CPT code 99214?

CPT 99214 represents a Level 4 established patient office visit requiring moderate-complexity MDM or 30–39 minutes of total provider time, supported by detailed documentation.

What is CPT code 99213?

CPT 99213 is a Level 3 established patient visit involving low-complexity MDM or 20–29 minutes of total provider time, commonly used for stable or minor conditions.

What is the difference between CPT 99213 and 99214?

The difference is based on MDM complexity, time, data review, and risk. 99213 is for low complexity, while 99214 applies to moderate complexity visits.

When should CPT 99213 be used?

Use 99213 for visits involving stable conditions, minimal data review, low risk, and 20–29 minutes of total provider time.

What qualifies for CPT 99214?

CPT 99214 requires moderate-complexity MDM, such as multiple diagnoses, medication adjustments, lab or imaging review, and 30–39 minutes of total provider time.

What is Modifier 55?

Modifier 55 indicates postoperative management only, used when one provider performs the surgery and another provides postoperative care.

How is Modifier 25 used?

Modifier 25 is appended to an E/M code when a significant and separately identifiable E/M service is performed on the same day as a procedure (e.g., 99213-25 or 99214-25). Proper documentation is required.