Wiki 99214 - criteria for billing

[sixfoot6]

What is the criteria for billing 99214 and getting paid according to Medicare guidelines

 

[dclark7]

An established patient requires two out of three of the following components:
1) Detailed history
2) Detailed exam
3) Moderate decision making

Remember however that medical necessity is the main criteria for choosing any code, so if the medical necessity is not there it doesn't matter how much documentation you have, you can't bill a 99214.

Doreen, CPC

 

[m.j.kummer]

An established patient requires two out of three of the following components:
1) Detailed history
2) Detailed exam
3) Moderate decision making

Remember however that medical necessity is the main criteria for choosing any code, so if the medical necessity is not there it doesn't matter how much documentation you have, you can't bill a 99214.

Doreen, CPC

To determine the level only two of three are required …

For example:
A problem focused exam and detailed history and moderate medical decision making, equals a 99214. There is an exam but you do not have to consider that it was only a problem focused exam to determine that you can bill a 99214 based on medical decision making.

In the same way, it is not appropriate to report 99214 with a detailed exam and history, and problem focused medical decision making because the detailed history and exam are not medically necessary (unless the history and exam were medically necessary to determine that the medical decision making was problem focused, which in the case of an established patient would be the exception rather than the rule).

Another way that a 99214 can be reported is if the encounter is based on time and all of the required elements for billing based on time are documented.