CPT 99214

Office Visit - Established Patient - Moderate Complexity

Established patient office visit with moderate level of medical decision making.

25-30 minutes
1.92 work RVU
4 requirements

Documentation Requirements

  1. 1Chief complaint and detailed HPI
  2. 2Moderate complexity medical decision making OR 30-39 minutes total time
  3. 3Problem-focused assessment and management
  4. 4Moderate risk treatment or data complexity

Billing Tips

  • •Document 2+ chronic illnesses with mild exacerbation OR 1 illness posing threat to life/function
  • •Independent interpretation of diagnostic data supports moderate MDM
  • •Prescription drug management is moderate risk minimum
  • •Time-based: 30-39 total minutes on encounter date

Frequently Asked Questions

What MDM elements support 99214?

Moderate MDM requires 2 of 3: multiple chronic conditions, moderate data complexity (independent interpretation, review of prior records), OR moderate risk treatment (prescription drugs, minor surgery with risk factors).

How does Scribeable help with 99214 documentation?

Scribeable identifies elements supporting moderate MDM from your conversation—chronic conditions discussed, data reviewed, medications prescribed—and ensures complete documentation for proper billing.

Automate Office Visit Level 4 Documentation

Scribeable captures all required elements for CPT 99214 from your patient conversation. Generate compliant notes in seconds.

Common Diagnoses

I10E11.65J44.1F32.1

Related Specialties

primary careinternal medicinecardiologyneurology

Related Procedures

CPT 992131.30 work RVU

Office Visit Level 3

Established patient office visit with low level of medical decision making.

CPT 992152.80 work RVU

Office Visit Level 5

Established patient office visit with high level of medical decision making.

CPT 992031.60 work RVU

New Patient Level 3

New patient office visit with low level of medical decision making.

CPT 992042.60 work RVU

New Patient Level 4

New patient office visit with moderate level of medical decision making.

CPT 99214: Office Visit - Established Patient - Moderate Complexity

Established patient office visit with moderate level of medical decision making.

Documentation Requirements

  1. Chief complaint and detailed HPI
  2. Moderate complexity medical decision making OR 30-39 minutes total time
  3. Problem-focused assessment and management
  4. Moderate risk treatment or data complexity

Billing Tips

  • Document 2+ chronic illnesses with mild exacerbation OR 1 illness posing threat to life/function
  • Independent interpretation of diagnostic data supports moderate MDM
  • Prescription drug management is moderate risk minimum
  • Time-based: 30-39 total minutes on encounter date

Frequently Asked Questions

What MDM elements support 99214?

Moderate MDM requires 2 of 3: multiple chronic conditions, moderate data complexity (independent interpretation, review of prior records), OR moderate risk treatment (prescription drugs, minor surgery with risk factors).

How does Scribeable help with 99214 documentation?

Scribeable identifies elements supporting moderate MDM from your conversation—chronic conditions discussed, data reviewed, medications prescribed—and ensures complete documentation for proper billing.

Related Procedures

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