CPT 99213 vs 99214: How to Pick the Right E/M Level Every Time

The 2021 Reset: Why the Rules Changed

Before 2021, choosing between 99213 and 99214 depended on counting documentation elements: history components (HPI, ROS, PFSH), exam elements (organ systems examined), and medical decision making (MDM) complexity. The 1995 and 1997 CMS Documentation Guidelines turned E/M coding into a documentation exercise—physicians added more ROS items and exam bullets to justify higher codes rather than selecting the code that reflected the actual clinical complexity of the visit.

The 2021 AMA/CPT revisions eliminated history and exam as coding determinants for established patient office visits. Starting January 1, 2021, you select the E/M level using either:

1. Medical Decision Making (MDM), assessed at the time of the encounter, OR
2. Total Time spent on the encounter date of service (including pre-visit chart review, the visit itself, and post-visit work like ordering, documentation, and referrals)

You choose whichever method supports the higher level—you are not required to use both, and you do not need both to align.

Established Patient Code Comparison: 99213 vs 99214

CPT 99213 vs 99214 at a Glance (Established Patients, 2021+ Guidelines)

Element	99213 (Level 3)	99214 (Level 4)
MDM complexity	Low	Moderate
Total time threshold	20–29 minutes	30–39 minutes
2026 Medicare national rate (non-facility)	~$85–$95	~$130–$150
Typical visit	Stable chronic condition, minor acute problem	Multiple chronic conditions, new problem with workup

Note: Medicare rates vary by geographic locality. The figures above are approximate national averages. Check the current CMS Physician Fee Schedule for your MAC region.

Medical Decision Making: The Three-Part Test

MDM is assessed across three elements. The overall MDM level equals the level of complexity for at least two of the three elements:

Element 1: Number and Complexity of Problems

Low MDM (supports 99213):

• One self-limited or minor problem (e.g., viral URI, wart)
• One stable chronic illness (e.g., well-controlled hypertension, stable hypothyroidism)
• Two or more self-limited or minor problems

Moderate MDM (supports 99214):

• One or more chronic illnesses with exacerbation, progression, or side effects of treatment
• Two or more stable chronic illnesses
• One undiagnosed new problem with uncertain prognosis
• One acute illness with systemic symptoms (e.g., pneumonia, appendicitis)
• One acute complicated injury

Element 2: Amount and/or Complexity of Data Reviewed

Low MDM (supports 99213):

• Limited or no data reviewed
• Simple ordering (one test, one referral) OR review of external records

Moderate MDM (supports 99214): Must meet at least one of three categories:

• Category 1: Tests, documents, or independent historian—review of prior external note AND ordering/reviewing results of a test (requires 3 of: review of prior external note, review of result of each unique test, ordering each unique test, assessment requiring independent historian)
• Category 2: Assessment requiring independent interpretation of tests ordered by another provider
• Category 3: Discussion of management with external provider

Element 3: Risk of Complications and/or Morbidity or Mortality

Low MDM (supports 99213):

• OTC drug management
• Minor surgery with no identified risk factors
• Rest, gargles, superficial dressings

Moderate MDM (supports 99214):

• Prescription drug management
• Minor surgery with identified risk factors
• Elective major surgery (no identified risk factors)
• Diagnosis or treatment significantly limited by social determinants of health
• Decision regarding hospitalization

Clinical Examples: 99213 or 99214?

Example 1: Stable Hypertension Follow-Up

Patient: 58-year-old established patient. Presents for blood pressure recheck. BP 128/82. On lisinopril 10mg daily, tolerating well. No complaints. Refill requested.

MDM analysis:

• Problems: One stable chronic illness → Low
• Data: Prescription refill only → Low (or Minimal)
• Risk: Prescription drug management → Moderate

Result: 99213. Two of three MDM elements are Low; the one Moderate element (prescription management) is not enough to elevate to Moderate overall MDM.

Example 2: Hypertension + Diabetes Follow-Up with Lab Review

Patient: 62-year-old established patient. Presents for diabetes and hypertension follow-up. A1c returned at 8.2% (up from 7.4% at last visit). Reviewing today's labs. Adjusting metformin dose. Prescribing low-dose statin after reviewing lipid panel. Discussed lifestyle changes.

MDM analysis:

• Problems: Two stable chronic illnesses (hypertension + diabetes), with one showing progression (A1c increase) → Moderate
• Data: Review of two test results (A1c, lipid panel), ordering statin (prescription) → Moderate (meets Category 1)
• Risk: Prescription drug management (two prescriptions adjusted) → Moderate

Result: 99214. All three MDM elements are Moderate.

Example 3: New-Onset Chest Pain Evaluation

Patient: 54-year-old established patient. New complaint of exertional chest tightness for 2 weeks. Ordered EKG (reviewed today, normal), ordered stress test, discussed cardiac risk factors. Will review stress test results and follow up.

MDM analysis:

• Problems: New problem with uncertain prognosis → Moderate
• Data: Ordered and reviewed EKG, ordered stress test → Moderate
• Risk: Ordering of a diagnostic test with potential for significant morbidity (cardiac workup) → Moderate

Result: 99214. Clearly Moderate MDM across all three elements.

Using Total Time Instead of MDM

Total time is an equally valid alternative. If your MDM analysis is unclear or borderline, document total time instead. Total time includes:

• Pre-visit chart review (before the patient arrives)
• Time with the patient (face-to-face or telehealth)
• Post-visit work on the same calendar date: ordering tests, reviewing results, writing referrals, coordination with staff

Time does NOT include time spent by clinical staff (nursing, MA). It is the physician's or qualified non-physician practitioner's time only.

To bill 99214 by time, document: "Total time spent on 8/8/2026 for this encounter: 32 minutes, including 10 minutes pre-visit chart review, 18 minutes with patient, 4 minutes post-visit orders and referral coordination."

Documentation Tips to Support Your Code Selection

For MDM-based coding: Your note must support the MDM level you select. You do not need to use specific documentation templates, but the note content must reflect the clinical complexity claimed. Auditors look for consistency between the problem list, the assessment and plan, and the MDM level billed.

For time-based coding: The total time must be documented explicitly in the note. A vague statement like "this was a complex visit" is not sufficient. Write the specific total minutes and briefly describe the activities included.

Do not under-code to avoid audits. Systematic under-coding (billing 99213 for visits that clearly support 99214) is a real revenue problem. A practice seeing 20 established patients daily that under-codes 30% of its 99214s by one level loses approximately $45–$60 per under-coded visit—$27,000–$36,000 annually for a solo physician.

AI-Assisted E/M Level Suggestion

Modern AI-native EMRs analyze the clinical content of a note and suggest the appropriate E/M level based on documented MDM elements. This is not automatic upcoding—it is a prompt for the physician to confirm or reject the suggestion, with the MDM rationale visible. For borderline visits (especially the 99213/99214 boundary), an AI coding suggestion backed by the actual MDM analysis gives you confidence in your selection and documentation to support it if audited.

Krasyn's billing review surface provides real-time E/M level suggestions based on note content, flags potential under-coding, and surfaces the specific MDM elements supporting each suggestion. See the billing review workflow in action.