What is a 99214 for E and M Coding?

For a physician, nurse practitioner or physician assistant to be compensated for the services they provide to a patient they must correctly document the events that occurred in the room.  While most medical practitioners document the items, they feel are pertinent, however, CMS has specific criteria that must be documented for each level of service.

The E and M code 99214 is the specific code for an established patient Level 4 patient and is used very frequently risk.  The reason the 99214 is used so often is based on two components. First, patients presenting for medical care typically meet the moderate risk criteria.  Secondly, CMS understands that less history and exam are needed to treat an established patient. 

The items needed to code for this Level of service are made up of the 3 components of the progress note.  For an established patient only 2 out 3 components must be met.

1.) History-

  1. History of present illness- Duration, location, severity, modifying factors, associated symptoms, context, quality, and timing

  2. Past medical family and social history

  3.  Review of Systems – 14 recognized systems

  • Constitutional (e.g., fever, weight loss)

  • Eyes

  • Ears, Nose, Mouth, Throat

  • Cardiovascular

  • Respiratory

  • Gastrointestinal

  • Genitourinary

  • Musculoskeletal

  • Integumentary (skin and/or breast)

  • Neurological

  • Psychiatric

  • Endocrine

  • Hematologic/Lymphatic

  • Allergic/Immunologic 

2.) Exam- The physical exam component is comprised of 

  • Constitutional (e.g., vital signs, general appearance)

  • Eyes

  • Ears, nose, mouth, and throat 

  • Cardiovascular 

  • Respiratory 

  • Gastrointestinal 

  • Genitourinary 

  • Musculoskeletal 

  • Skin 

  • Neurologic

  • Psychiatric 

  • Hematologic/lymphatic/immunologic

3.) Medical Decision Making 

  1. Diagnosis

  2. Treatment options- Medications, referrals, splints, etc..

  3. Data review – Old records, labs, medical tests, imaging, etc…

  4. Level of Risk – Minimal, low, moderate and high

For an established 99214 the following items must be met for two out of three components.  It can be any combination of the components.

  1. History – Four element of HPI, two systems reviewed, and one PMFSH reviewed

  2. Exam- Minimum of two systems (with one being detailed) and a maximum of seven systems

  3. Moderate risk complaint and needs to have either: three diagnosis, three treatment option or three data review.

Example: 99214

51 yo male here for a complaint of moderate chronic seasonal allergies for 2 years and has used OTC Flonase with mild relief.  The patient states the symptoms are worse in the fall.

PMFSH – all reviewed

ROS – Ear, nose throat - positive for nasal congestion


            Respiratory – Positive for cough


Exam – General – well developed well-nourished


ENT – clear nasal discharge noted, bilateral tympanic membranes without erythema, posterior  pharynx with post nasal drip noted


Diagnosis – 1.)  Seasonal allergies

                     2.) Cough

Treatment – Singulair 10 mg – 1 tab PO daily x 30 days

  • (HPI components)

  • (ROS systems)

  • (Systems examined ENT detailed)

As you can see from the above example or a 99214 the complexity of the patient and amount of exam required are very simple for the seasoned practitioner.

The other option for billing for Evaluation and management codes is the unit of time.  For a 99203 the practitioner must spend at least 25 minutes face to face with the patient and half of the time spent counseling the patient on treatment, lab results, and planning.  All these components should be documented.