99213 or 99214? Three Tips for Navigating the Coding Conundrum

Richelle Marting, JD

Fam Pract Manag. 2018;25(4):5-10.

Abstract and Introduction

Introduction

Perhaps one of the most confounding aspects of evaluation and management (E/M) coding is the distinction between a 99213 and a 99214 visit. Some may view this as a distinction without a difference, but medical practices that confuse the two codes either forfeit revenue earned or risk penalties for upcoding.

Family physicians provide a staggering number of established patient office visits each year — 38,249,187 in 2016, according to the Centers for Medicare & Medicaid Services (CMS).^[1] Of those, 42 percent were reported as 99213 visits and 50 percent were reported as 99214 visits. With these two codes accounting for such a large proportion of office visits, and with a difference of about $35 per visit (using the national average Medicare allowed amounts), the distinction between the two can quickly become significant. For example, 250 Medicare visits coded 99213 rather than 99214 amounts to nearly $9,000 less revenue.

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Sidebar

Key Points

With 42 percent of office visits to family physicians reported as 99213s and 50 percent reported as 99214s, and with a difference of about $35 per visit, the distinction between these two levels can quickly become significant.
Remember 4, 2, 1 for the detailed history of a 99214 — four elements of the history of present illness, two organ systems reviewed, and one element of the past medical, family, and social history.
One way to remember the requirements for a detailed exam consistent with a 99214 is the 4x4 method — four items of exam in four different body areas/organ systems.
Think 99214 if the presenting problem involves a chronic condition with exacerbation, multiple stable chronic conditions, an acute complaint with systemic symptoms, an acute complicated injury, or an undiagnosed new problem with uncertain prognosis.

Changes Coming to the E/M Guidelines

In June 2017, in the proposed rule for the 2018 Medicare physician fee schedule, the Centers for Medicare & Medicaid Services (CMS) sought feedback about the E/M guidelines, noting that they have heard from stakeholders that the guidelines are overly burdensome and outdated.

In November 2017, the final rule described the comments CMS received (https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1676-F.html), and in March 2018, CMS convened a listening session to gather more feedback about the E/M guidelines (https://www.cms.gov/Outreach-and-Education/Outreach/NPC/Downloads/2018-03-21-Documentation-Guildlines-and-Burden-Reduction-Transcript.pdf).

Some commenters noted that the guidelines are inconsistent with the current emphasis on team-based care and should therefore be revised to allow any member of the care team to enter medical information related to a visit. Others suggested eliminating or reducing the history and exam components and allowing medical decision making and/or time to serve as the key determinant of an E/M visit level. Still others called for eliminating the guidelines altogether for codes 99211–99215 and 99201–99205. You can read the American Academy of Family Physician's written comments to CMS here: https://www.aafp.org/dam/AAFP/documents/advocacy/payment/medicare/LT-CMS-EMSuggestions-042318.pdf.

At press time, CMS had not yet released its proposed changes to the E/M guidelines, but they are expected to be part of the 2019 proposed Medicare physician fee schedule. Following a brief comment period, the final rule will be released at the end of October.

Using Time as the Controlling Factor

When selecting a level of service based on time, the distinction between a 99213 and 99214 visit is relatively straightforward. You can take this route when counseling and coordination of care comprise more than half of your face-to-face time with the patient (staff time with the patient does not count).

Counseling includes discussion with the patient or family concerning one or more of the following:

Diagnostic results, impressions, or recommended diagnostic studies,
Prognosis,
Risks and benefits of management (treatment) options,
Risk factor reduction,
Patient and family education.

You do not need to complete a history or physical exam to select the level of service based on time unless it is medically necessary. For example, if a patient is returning to discuss the findings of a test you ordered at a previous visit, there may be no need to repeat a full history and exam at the current visit. Simply document the total time of the visit and the amount of time spent in counseling or coordination of care activities. A detailed description of the counseling provided isn't required; a summary is all that is necessary for most payers.

The times listed in the CPT code descriptors are averages, not thresholds, so select the code closest to the time spent. For example, if the total duration of face-to-face physician-patient time is 21 minutes, select code 99214 because the duration of visit is closer to 25 minutes, the average time for a 99214, than it is to 15 minutes, the average time for a 99213.