99213 or 99214? Three Tips for Navigating the Coding Conundrum


Here’s how to quickly identify whether you’re on the path to a 99214 versus a 99213.

Fam Pract Manag. 2018 Jul-Aug;25(4):5-10.

Author disclosure: no relevant financial affiliations disclosed.

Perhaps one of the most confounding aspects of evaluation and management (E/M) coding is the distinction between a 99213 and a 99214 visit. Some may view this as a distinction without a difference, but medical practices that confuse the two codes either forfeit revenue earned or risk penalties for upcoding.

Family physicians provide a staggering number of established patient office visits each year — 38,249,187 in 2016, according to the Centers for Medicare & Medicaid Services (CMS).1 Of those, 42 percent were reported as 99213 visits and 50 percent were reported as 99214 visits. With these two codes accounting for such a large proportion of office visits, and with a difference of about $35 per visit (using the national average Medicare allowed amounts), the distinction between the two can quickly become significant. For example, 250 Medicare visits coded 99213 rather than 99214 amounts to nearly $9,000 less revenue.


On July 12, CMS released its proposed changes to the Medicare Physician Fee Schedule for 2019. The proposed rule contains, among other updates, significant revisions to the coding and documentation of office visit E/M services.

Read a summary of the proposed changes here.

Following a brief comment period, the final rule will be released at the end of October.


In June 2017, in the proposed rule for the 2018 Medicare physician fee schedule, the Centers for Medicare & Medicaid Services (CMS) sought feedback about the E/M guidelines, noting that they have heard from stakeholders that the guidelines are overly burdensome and outdated.

In November 2017, the final rule described the comments CMS received, and in March 2018, CMS convened a listening session to gather more feedback about the E/M guidelines.

Some commenters noted that the guidelines are inconsistent with the current emphasis on team-based care. Others suggested eliminating or reducing the history and exam components and allowing medical decision making and/or time to serve as the key determinant of an E/M visit level. Still others called for eliminating the guidelines altogether for codes 99211-99215 and 99201-99205. You can read the American Academy of Family Physician’s written comments to CMS here.


The E/M documentation guidelines require that established patient office visits meet two of three key components of the E/M code being reported. Alternatively, if more than half the visit involves counseling or coordination of care, the visit may be reported based on time. (See “Key components and average times for codes 99213 and 99214.”)


Richelle Marting is an attorney practicing with Forbes Law Group in Overland Park, Kan., where she focuses on regulatory compliance and health care reimbursement.

Author disclosure: no relevant financial affiliations disclosed.


show all references

1. Medicare Part B Physician/Supplier National Data CY2016, Evaluation and Management Codes by Specialty. https://go.cms.gov/2JQqN0N. Accessed May 25, 2018....

2. Specialty Exam and E&M Score Sheets. Novitas Solutions website. https://bit.ly/2xmklJE. Accessed May 25, 2018.

3. Centers for Medicare & Medicaid Services. Evaluation and Management Services. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf. Updated August 2017. Accessed May 25, 2018.

4. Bowman S. Impact of electronic health record systems on information integrity: quality and safety implications. Perspect Health Inf Manag. 2013;10:1C.

5. American College of Emergency Physicians. Evaluation and Management Documentation Requirements — CMS vs. CPT. https://www.acep.org/administration/reimbursement/documentation-guidelines/evaluation-and-management-documentation-requirements--cms-vs.-cpt. Accessed May 25, 2018.


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