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.
2. Pick a method for documenting a detailed exam.
3. Think in threes 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.”
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