Evaluation & management · General
Office visit for an established patient requiring moderate-complexity medical decision making (MDM), or 30–39 minutes of total provider time on the date of service.
Verified May 8, 2026 · 6 sources ↓
- Medicare
- $135.61
- Total RVUs
- 4.06
- Global, days
- Region
- General
Documentation requirements
What must appear in the operative or office note to support the claim.
Source · Editorial brief grounded in 6 cited references ↓
- Chief complaint clearly stated in the record
- Relevant interval history and review of systems if performed
- MDM documentation addressing at least two of three elements: problem complexity, data reviewed, and risk — OR total provider time recorded in minutes with a specific notation that time was used for level selection
- Explicit link between clinical findings and the selected service level (medical necessity statement)
- For time-based billing: all contributing activities on the date of service itemized, not just face-to-face time
- For same-day procedures: documentation that the E/M was significant and separately identifiable from the procedure to support modifier 25
Applicable modifiers
Modifiers commonly billed with this code.
Source · AMA CPT modifier descriptors · CMS NCCI Policy Manual
What this code covers
Source · Editorial summary grounded in 6 cited references ↓
99214 is the level-4 established-patient office visit. It applies when the encounter involves moderate-complexity MDM — typically one or more worsening chronic conditions, two or more stable chronic conditions, or an acute illness with systemic symptoms — or when total provider time on the date of service falls between 30 and 39 minutes. Since the 2021 E/M overhaul, providers choose one pathway: MDM or time. Whichever you select, the documentation must support that choice explicitly; you can't blend criteria from both columns to reach level 4.
MDM at moderate complexity requires satisfying at least two of three elements: the number and complexity of problems addressed, the amount and/or complexity of data reviewed, and the risk of complications and/or morbidity. For time-based billing, count all time personally spent by the billing provider on the date of service — face-to-face and non-face-to-face (reviewing records, ordering tests, communicating with other providers). The clock starts and stops on the calendar date, not the visit duration.
99214 is the single most frequently misreported E/M service to Medicare per the HHS FY2024 agency financial report, making it a persistent audit target. Upcoding from 99213 and underdocumented MDM are the two most common findings. If you're billing 99214 on the same day as a procedure with a global period, modifier 25 is required on the E/M to demonstrate a significant, separately identifiable service.
RVU & reimbursement
Component RVUs and Medicare national rate. Actual payment varies by GPCI locality.
Source · CMS Physician Fee Schedule, RVU26A · January 2026
| Work RVU | 1.92 |
| Practice expense RVU | 2 |
| Malpractice RVU | 0.14 |
| Total RVU | 4.06 |
| Medicare national rate | $135.61 |
| Global period | days |
Payment by site of service
Medicare pays different rates by setting. HOPD typically pays substantially more than ASC for the same procedure.
Source · CMS OPPS Addendum B·ASC HCPCS payment rates·2026
| Setting | Medicare rate (national) |
|---|---|
Office (PFS non-facility) Procedure performed in physician's office | $135.61 |
Common denial reasons
The recurring reasons claims for CPT 99214 get rejected.
Source · Editorial brief grounded in CMS NCCI edits, AAOS coding appeals, and cited references ↓
- MDM complexity not supported — documentation reflects straightforward or low-complexity decision making, warranting 99213 instead
- Time not documented — provider selected time-based billing but failed to record total minutes or specify that time drove the level selection
- Missing modifier 25 when 99214 is billed same-day as a procedure that carries a global period
- Cloned or templated notes that lack patient-specific findings, flagged as not supporting the reported service level
- Established patient status not confirmed — payers may downcode or deny if patient relationship cannot be verified in the practice
Frequently asked questions
Source · Generated from the editorial pipeline, verified against 6 cited references ↓
01What's the difference between billing 99214 by MDM versus by time?
02Does 99214 require a detailed history and exam under 2021 E/M guidelines?
03Can I bill 99214 on the same day as a minor procedure?
04Why is 99214 flagged so often in Medicare audits?
05What qualifies as moderate-complexity MDM for 99214?
06Can a non-physician provider (NP or PA) bill 99214?
Sources & references
Editorial content was developed using the following public sources. Last verified May 8, 2026.
- 01ama-assn.orghttps://www.ama-assn.org/practice-management/cpt/cpt-code-99214-established-patient-office-visit-30-39-minutes
- 02cms.govhttps://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=56006&ver=19
- 03cms.govhttps://www.cms.gov/files/document/medicare-ncci-policy-manual-2024-chapter-11.pdf
- 04brellium.comhttps://brellium.com/articles/cpt-code-99214-documentation-requirements-compliance-guide
- 05tebra.comhttps://www.tebra.com/theintake/getting-paid/e-m-code-99214-medicare-improper-payments
- 06CMS Physician Fee Schedule 2026
Mira AI Scribe
Mira's AI scribe captures the total provider time on the date of service, the specific chronic or acute conditions addressed, the MDM elements (problem complexity, data reviewed, and risk level), and any care coordination activities performed outside the face-to-face encounter. This prevents the most common 99214 audit finding: a note that documents the visit content but omits the explicit MDM rationale or total time needed to defend the level-4 selection.
See how Mira captures CPT 99214 documentation