E/M code 99214 tops HHS’ list of Medicare improper payments

It’s the battle of the Current Procedural Terminology (CPT) codes: 99213 vs 99214. Which one is the right evaluation and management (E/M) code to report based on clinical documentation? Providers and medical billing companies have a 50/50 chance of getting it right, and unfortunately, many choose wrongly much of the time. 

In fact, CPT code 99214 (level 4 established patient office visit) was the most erroneous E/M code reported to Medicare in 2023, according to the 2024 Medicare fee-for-service (FFS) supplemental improper payment data. The United States Department of Health and Human Services (HHS) released this supplemental data commensurate with its fiscal year 2024 agency financial report detailing an overall estimated Medicare FFS improper payment rate of 7.66%, or $31.70 billion. 

Ranking at the top of the Medicare improper payments list is particularly problematic given that 99214 was also the most-billed level 1 CPT code submitted to Medicare payers, according to the most recent Centers for Medicare & Medicaid Services (CMS) data (which reflected claims submitted in calendar year 2023). However, on the flip side, this also means efforts to improve 99214 compliance can have a significantly favorable impact on the overall Medicare FFS improper payment rate.

According to the supplemental improper payment data, CMS made $564,563,132 in improper payments for 99214, more than half of which (63.4%) involved incorrect coding. Another 20.1% of improper payments were due to "no documentation," while 16.5% stemmed from "insufficient documentation."

Other important findings in the supplemental improper payment data include the following:

Although E/M changes that took effect January 1, 2021 simplified the process of code assignment for all levels of E/M codes (allowing physicians to select codes based on time or medical decision-making (MDM), depending on which is more advantageous), many questions and concerns specifically about 99214 remain. This includes concerns about denials as well as accusations of upcoding that could lead to audits and recoupments. 

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Following are 5 steps based on CPT code 99214 guidelines to help providers and medical billing companies avoid CMS improper payments. 

To bill based on time, physicians must meet or exceed 30 minutes of total time on the date of the encounter. [Note that this is new for 2024. In 2023, this code had a 30- to 39-minute range.] If the medical practice’s electronic health record (EHR) has a time calculator, physicians should use it. When billing based on time, physicians must document the total time spent on the visit that day and a short description of what they did during that time. 

In addition to face-to-face time in the exam room or in a telehealth encounter, "total time spent" also includes prep time and follow-up work on that same date. Billing based on time may be most advantageous for low-acuity visits that require significant physician time (e.g., to review tests; obtain or review separately obtained history; perform a medically necessary appropriate exam; counsel and educate their patient or their caregiver; order medications, tests, or procedures; or document clinical information in the record).

According to the 99214 billing guidelines, 2 of the 3 elements of MDM (i.e., number and complexity of problems addressed, amount and/or complexity of data reviewed and analyzed, or risk of complications and/or morbidity and mortality) must be "moderate." Use the MDM table to understand what constitutes moderate MDM.

Adding the current medication list to the progress note does not justify counting prescription drug management toward the MDM. There must be evidence in the documentation that a physician has evaluated medications as part of a service they provided. 

Documentation should also reflect a direct connection between the medication and the work performed on the day of the visit. In addition, physicians cannot count labs at the time of the order and when they review them at the follow-up appointment. They should only count them on the date on which they order them, per the American Medical Association (AMA).

According to the AMA, 99214 is generally reserved for established patients with a progressing illness or acute injury that requires medical management or potential surgical treatment. However, the association acknowledges that this description certainly does not describe the universe of patients for whom the service would be appropriate. Still, this explanation can be helpful when initially thinking about 99213 vs 99214.

To avoid CMS improper payments, do not include separately billable services in your MDM or total time calculation.

Here’s an article from American Academy of Family Physicians (AAFP) that includes office visit notes supporting 99214 based on time as well as examples supporting 99214 based on MDM. This AAFP article also provides helpful pointers on how to simplify E/M coding and documentation. In addition, this whitepaper from the AMA explains how to ensure clinical documentation supports the E/M code assigned.

When justified, reporting 99214 ensures revenue integrity. However, as with all E/M codes, clinical documentation must clearly indicate why 99214 is appropriate. 

If clinical documentation doesn’t support 99214 billing guidelines, providers and medical billing companies should not report this code. To avoid Medicare improper payments, they should always strive for compliance and review CPT code 99214 guidelines before selecting the E/M level.