CPT 99214: Office Visit - Established Patient - Moderate Complexity
Documentation Requirements
- Chief complaint and detailed HPI
- Problem-focused assessment and management
- Moderate risk treatment or data complexity
Billing Tips
- Independent interpretation of diagnostic data supports moderate MDM
- 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.