How to Bill 99214

In order to bill 99214 you must document according to the standard in:

2 of these 3 elements:

1. Detailed History

Appropriate history includes the chief complaint plus all 3 of these:

History of Presenting Illness: 4 elements including location, duration, quality, timing, severity, or context.

Past, Family, or Social History: Only need 1 of these, and automated listing of drug allergies or medications counts.

Review of Systems: 2 or more pertinent elements.

2. Detailed Physical Examination

Vitals signs plus eleven physical exam elements in at least two organ systems.

3. Moderate Medical Decision Making

Moderate medical decision making requires 2 of the following 3 elements:

1. Three Problem Points

• Self-limited or minor problems (maximum of 2): 1 point each
• Established problem, stable or improving: 1 point each
• Established problem, worsening: 2 points each
• New problem, with no additional work-up planned: 3 points
• New problem, with additional work-up planned: 4 points

2. Three Data Points

• Review or order clinical lab tests: 1 point
• Review or order radiology: 1 point
• Review or order medicine test (PFTs, EKG, cardiac echo): 1 point
• Discuss test with performing physician: 1 point
• Independent review of image, tracing, or specimen: 2 points
• Decision to obtain old records: 1 point
• Review and summation of old records: 2 points

3. Moderate Risk

Moderate risk is met if any one of the following is true:

• One or more chronic illness, with mild exacerbation, progression, or side effects of treatment (e.g. adverse effects from ADHD medication)
• Two or more stable chronic illnesses
• Undiagnosed new problem, with uncertain prognosis (e.g. lump in breast)
• Acute illness, with systemic symptoms
• Acute complicated injury (e.g., head injury, with brief loss of consciousness)
• Prescription drug management