When it comes to medical billing, choosing the right CPT code is essential for clinics and healthcare organizations because some CPT codes are quite similar and can cause confusion while using them, leading to an impact on reimbursement. Some of the most frequently used CPT codes are 99213 vs 99214; both are specially designed for patient care.
However, sometimes organizations make mistakes and use any of the CPT codes because they seem similar, but there’s a key difference.
In this article, we will understand everything about CPT code 99213 vs 99214, documents required, examples and key differences between them. So that healthcare organizations and clinics can use these CPT codes accurately during the reimbursement.
What is CPT Code 99213?
CPT code 99213 is a medical billing code which is used to describe an evaluation and management (E/M) service provided by a healthcare organization to established patients during an office or outpatient visit. This CPT code is applied to the situation where the patient’s condition is of low to moderate complexity, requires a moderate level of care and decision-making, and typically spends around 20 minutes or more on the patient visit, then it’s considered as CPT Code 99213.
Key Points to Consider:
- Patient Type: Established patientÂ
- Visit Type: Office or outpatient visit
- Time Spend: 20 minutes or more
- Complexity: Low-level complexity
Examples of Common Uses of CPT Code 99213
- Minor Illness: Patients who experience minor illnesses like a common cold, sore throat or mild food poisoning may often require basic evaluation and care. Where the doctor reviews the patient’s symptoms and performs a focused examination to provide treatment options and medications.
- Routine Check-ups for Chronic Conditions: This code is also used when an established patient does follow-up visits for stable chronic conditions such as controlled diabetes or high blood pressure. For example, a slight increase in blood sugar or blood pressure without complications can lead the doctor to adjust medications and provide dietary advice.
- Medical Refills and Follow-ups: Patients who regularly take medications, such as inhalers for asthma, may visit their healthcare provider for prescription renewals. During these visits, doctors ensure that the condition is stable and that the necessary prescription after a brief assessment.
What is CPT Code 99214?
CPT Code 99214 is commonly used by healthcare organizations for complex outpatient visits with established patients, which typically take 25 minutes. This code is applied when a patient’s care involves moderate complexity, such as managing multiple medical conditions or addressing more serious symptoms. The reimbursement rate for this CPT code is higher than 99213 because it includes face-to-face time spent between patient and physician.
Key Points to Consider:
- Patient Type: Established patientÂ
- Visit Type: Office or outpatient visit
- Time Spend: 20 minutes or more
- Complexity: Moderate-level complexity
Examples of Common Uses of CPT Code 99214
- Managing Multiple Ongoing Health Issues: If a patient has several ongoing health issues like diabetes, high blood pressure, etc, then they may visit a doctor for a check-up. During the visit, the doctor checks all health issues through tests and, based on the test results, provides the right medications and treatment options. This type of visit has multiple health issues covered under CPT Code 99214.
- Chronic Condition Leads to a New Health Problem: If a patient already has a chronic condition like lung disease and comes with new symptoms like shortness of breath, then the doctor might need to do an extra test. For example – if a doctor does a chest X-ray or lung function test to figure out what’s the problem and, based on the results, the doctor finds out that the doctor needs to make some adjustments in medications accordingly, then this type of visit is also counted in CPT code 99214.
Key Differences between CPT Codes 99213 Vs 99214
| Criteria | 99213 | 99214 |
|---|---|---|
| Time spend | 15 minutes | 25 minutes |
| MDM complexity | Low | Moderate |
| History and exam | Problem-focused | Detailed |
| Risk to patient | Low | Moderate |
| Reimbursement Rate | $90.88 | $128.16 |
Reimbursement Rates for E/M CPT Codes
The reimbursement rate for CPT codes 99213 vs 99214 varies depending on the insurance providers. Because insurance companies have their rates for evaluation and management (E/M) codes. Here are the estimated reimbursement rates for CPT codes 99213 vs 99214:
| CPT Code | Reimbursement Rates | ||
| Medicare | Medicaid | Commercial insurance rates | |
| 99213 | $89.39 | $45.69 | $95 |
| 99214 | $126.07 | $68.97 | $95 |
Before providing services, healthcare professionals should always confirm the patient’s insurance plan and eligibility to ensure accurate billing and avoid potential discrepancies with reimbursements.
Medical Billing and Coding Strategies For E/M Codes
By following the medical billing and coding services CPT codes efficiently, healthcare professionals can improve their revenue and patient care. Here are some essential strategies that can help healthcare professionals with accurate reimbursement:
1. Follow Time Guidelines
First, healthcare professionals need to keep track of the time spent with a patient. This helps prevent underbilling or overcharging during medical billing. Whenever a patient visits, note the time and details of the counselling carefully to find out which CPT code is suitable for that visit: 99213 or 99214.
2. Document Everything
When it comes to medical billing and coding, healthcare professionals need to document everything from the patient’s symptoms, doctor’s diagnosis, treatment plan and other things like the patient’s medical history, exam findings and follow-up plans. This can be documented with the help of the EHR system, which processes it more easily and ensures everything is recorded accurately.
3. Assess the Risk
As different CPT codes are used for different risk levels, healthcare professionals need to use the right CPT code based on the patient’s risk level from lower to moderate or severe Condition. For Ex – 99213 is used for lower-risk situations, and 99214 CPT code is used for moderate-risk conditions.
4. Stay Updated on Medical Coding Guidelines
Healthcare professionals need to stay updated with rules to avoid mistakes and ensure they’re following the right process during medical billing. So that the chances of claims being rejected and ensuring the healthcare practices get paid fairly.
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Conclusion
CPT codes 99213 and 99214 are the most frequently used codes for medical billing. Healthcare professionals need to know the key difference between 99213 and 99214 CPT Codes to use them effectively and fairly. We hope this guide helps you understand both 99213 and 99214 CPT codes, as well as examples and key differences. So that healthcare professionals can use the accurate CPT code for reimbursement.
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FAQs
Q1. What is CPT code 99213 used for?
CPT Code 99213 is used for office visits or outpatient visits where patients need care for minimal media issues. This visit typically involves reviewing a patient’s history, doing a specific examination, and making straightforward decisions.
Q2. What level of service is 99213?
CPT 99213 Code is classified as a level 3 Evaluation and Management (E/M) service.
Q3. Is 99213 a preventive code?
No, the 99213 CPT code is not intended for preventive care. It is used to address existing health concerns or follow up on treatment rather than routine check-ups.
Q4. Who can bill CPT code 99213?
Healthcare providers like doctors, nurses, practitioners and physician assistants can bill for CPT code 99213 if they meet the criteria for documentation and care.
Q5. What qualifies for CPT code 99214?
To use CPT Code 99214, the visit must involve a moderate level of complexity and more than 25 minutes of face-to-face time spent with a physician.
Q6. What does CPT code 99214 indicate?
CPT 99214 code indicates where the patient has more serious or multiple conditions that require more time for evaluation and a more detailed treatment plan.
Q7. Does CPT code 99213 need a modifier?
99213 CPT code doesn’t require a modifier. However, if other services are performed during the same visit, a modifier might be needed to clarify the nature of those procedures.
