CPT CODE 99214: Office or Other Outpatient Visit for the Evaluation and Management of an Established Patient, Level 4
In this quick reference guide to CPT code 99214, we answer frequently asked questions from our community of chiropractors. Follow us for other articles in our ongoing series, courtesy of ChiroTouch, the cloud-based EHR designed specifically for chiropractors.
About CPT Code 99214: Office or Other Outpatient Visit for the Evaluation and Management of an Established Patient, Level 4
CPT code 99214 pertains to an established patient office or other outpatient visit for evaluation and management (E/M) services. It involves three key components:
- Detailed history. A comprehensive information gathering about the patient’s current health concerns and relevant past medical history.
- Detailed examination. A thorough physical examination focused on the identified problems, potentially incorporating specific chiropractic tests or maneuvers.
- Moderately complex medical decision-making. Decisions about diagnosis, treatment plans, and prognosis based on the gathered information, with a moderate level of complexity.
Chiropractors can use this code to accurately bill for visits with established patients of moderate to high complexity.
Category or Type of Service
CPT code 99214 falls under the category of Evaluation and Management (E/M) services. As a level 4 E/M service, it is indicated by the last digit of the code.
This code is specifically designated for established patients, meaning the patient has been seen by the provider or a provider in the same specialty within the same practice within the past three years.
This code is typically billed per encounter. Code 99214 is for visits of moderate to high complexity, typically involving 30-39 minutes.
When Should Chiropractors Use This Code?
Chiropractors should use CPT code 99213 when they perform a detailed examination and management of an established patient’s health of moderate complexity. This code is appropriate for encounters that involve a thorough assessment, decision-making, and coordination of care.
Common scenarios where this code would be appropriate include encounters with patients who have complex health issues or cases where you or your staff spend a significant amount of time reviewing medical records and coordinating care with other healthcare providers.
When choosing among levels in the 99211-99215 series, prioritize medical decision-making (MDM) over length of visit as the primary factor in determining the correct code level. Time is a secondary but still important consideration.
|New patient office visit, level 1
|New patient office visit, level 2
|New patient office visit, level 3
|Established patient office visit, level 4
|Established patient office visit, level 5
|50 or more minutes
When Should Chiropractors Not Use This Code?
Chiropractors should avoid using CPT code 99214 for:
- New patients. Codes from the series 99201-99205 are used for new patient encounters.
- Routine follow-up visits. For routine follow-ups, consider lower-level codes based on the complexity of the visit.
- Initial evaluations. Opt for higher-level codes for comprehensive assessments.
- Simple chiropractic adjustments. Bill these separately unless the E/M service is significantly distinct and separately identifiable.
Which Modifiers Can Be Used With CPT Code 99214?
The following modifier codes are often used with CPT code 99214:
- Modifier 25. Signifies a separate and distinct E/M service performed on the same day as another procedure or service.
- Modifier 59. Indicates that a procedure or service was distinct or independent from other services performed on the same day.
- Modifier AT. Used to indicate a service or procedure performed for an acute or chronic subluxation. This modifier is mandatory for 99214 encounters billed to Medicare.
- Modifier 95. Signifies that the E/M service was delivered via interactive audio-video telecommunications technology.
- Modifier GT. Also used for telehealth services but is primarily used only in cases where insurance providers haven’t universally accepted modifier 95.
Always review and comply with payer-specific guidelines when using modifiers for accurate and compliant billing.
What Are the Billing Guidelines and Documentation Requirements Specific to This Code?
To ensure accurate billing, adhere to the following guidelines and documentation requirements for code 99214:
- Frequency of use. Check the patient’s insurance plan for billing code frequency limits.
- Established patient. Make sure there’s an existing patient-provider relationship.
- Face-to-face encounter. The provider must see the patient, either in person or via a telehealth system.
- Care provided. Conduct a thorough evaluation and management of the established patient during the visit. Be specific on clinical needs, provide care, and document decision-making regarding the treatment plan.
- Separate billing. If additional chiropractic services are provided on the same day, 99214 must be billed as a separate charge using modifier 59.
Have on hand clear, legible, and specific documentation signed and dated by the chiropractor. Documentation is one of the most useful ways to head off problems in the billing process.
Common Mistakes Made Specific to CPT Code 99214
Avoid these common mistakes when using code 99214:
- Excessive use. Keep this code for established patient visits with moderate to high complexity.
- Routine follow-ups. Pick lower-level codes for routine follow-up visits.
- Inadequate documentation. Write down detailed terminology that reflects the level of complexity.
- Mismatched coding. Check that the code chosen accurately reflects the level of service provided.
Thorough and detailed documentation is crucial for accurate billing and minimizing claim denials.
Potential Audit Triggers Specific to This CPT Code
Be aware of potential audit triggers for CPT code 99214:
- Inconsistent use of time. Document the actual level of E/M elements, not just time spent.
- Lack of supporting documentation. Provide clear evidence supporting the moderate to high level of complexity.
- Incorrect use of modifiers. Review the modifiers to make sure they’re used properly and are supported by documentation.
- Frequent use for routine visits. Make sure each use of the code meets its standards.
- Telehealth coding discrepancies. Keep your billing consistent regardless of platforms and use the right modifiers.
Improve the Accuracy and Efficiency of Your Practice’s Billing and Coding Processes
Chiropractors can enhance billing and coding processes by:
- Regularly reviewing billing and coding practices.
- Staying updated on changes to billing and coding regulations.
- Using ChiroTouch to leverage cloud-based EHR and practice management software designed for chiropractors.
By following these steps, chiropractors can ensure the accuracy and efficiency of their billing and coding practices, reducing the risk of claim denials and enhancing overall practice management.
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