• 99213 vs. 99214: Three tips for spotting the difference

    One of the most confounding aspects of evaluation and management (E/M) coding is the distinction between a 99213 and a 99214 established patient office visit.

    These visits must meet two of three key components listed below:

    Medical decision making
    99213 key components Expanded problem focused Expanded problem focused
    99214 key components Detailed

    Note: Alternatively, if more than half the visit involves counseling or coordination of care, the visit may be reported based on time.

    The following tips can help you recognize when a visit meets the requirements of a 99214, as opposed to a 99213.

    1. Remember 4, 2, 1 for a detailed history.

    • Four elements of the history of present illness (HPI),
    • Two organ systems in the review of systems (ROS),
    • One element of the past, family, and social history (PFSH).

      These elements are in addition to the chief complaint, unless the visit is preventive and has none.

    2. Pick a method for documenting a detailed exam.

    • The 12 bullet point method: Document at least 12 bullet points — whether normal or abnormal. (See the full list of bullet points on page 13 of the guidelines.)
    • The 5-7 method: Document findings in five to seven organ systems or body areas. At least one system should be in detail, but the rest can be in brief.
    • The 4x4 method: Document four items of exam in four different body areas/organ systems.

    3. Think in threes for moderate decision making.

    • Three points for diagnoses or management options (e.g., three points for a new problem with no additional work-up planned),
    • Three points for data reviewed (e.g., one point for reviewing labs and two points for reviewing old records),
    • Three options for moderate risk. The risk component doesn’t have points assigned to it, but here’s what to look for: a presenting problem such as a chronic condition with mild exacerbation, a diagnostic procedure such as a stress test, or a management option such as prescription drug management.

      Only two of the three would be required for moderate decision making.

    The Centers for Medicare & Medicaid Services recently proposed significant changes to the E/M documentation guidelines. Read the AAFP's initial comments on the proposed rule.

    Adapted from “99213 or 99214? Three Tips for Navigating the Coding Conundrum.” 

    Posted on Aug 22, 2018 by FPM Editors

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