CPT 99214: Office Visit - Established Patient - Moderate Complexity
Established patient office visit with moderate level of medical decision making.
Documentation Requirements
- Chief complaint and detailed HPI
- Moderate complexity medical decision making OR 30-39 minutes total time
- Problem-focused assessment and management
- 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.