If you’ve spent any time in outpatient care — family medicine, pediatrics, internal medicine, psychiatry, you name it.
Every clinician wrestles with this question, especially when the visit isn’t straightforward but not exactly complex either. Get it wrong, and you either leave money on the table or risk audits, recoupments, and those unwanted payer love letters.
The trick is understanding the real difference between these two codes — not just the textbook definitions you see in seminars, but the practical, everyday decision-making doctors use. Let’s break down the time, complexity, documentation, and billing rules in a way that feels human, not like wading through a CMS manual.
Understanding the Core Difference Between 99213 and 99214
At their core, 99213 = low-to-moderate complexity, while 99214 = moderate complexity.
Most clinicians already feel this difference instinctively, but the 2021 E/M guideline updates made things simpler by basing these codes primarily on:
- Medical Decision Making (MDM)
- OR Total Time spent on the date of service
These rules follow the CMS 2021–2024 Evaluation & Management (E/M) guidelines, which eliminated history and exam as scoring elements and prioritize Medical Decision Making or total time.
Both paths lead to the same place, but MDM is still the most common drive. Here’s the simplest way to think of it:
- 99213 is the patient you know well, with a problem you understand well. May it be its controlled chronic disease, medication refills, or a mild acute issue, that won’t keep you awake at night.
- 99214 is when things get layered — more symptoms, more uncertainty, more data to review, more risk, more decisions, more counseling, more change.
Many providers avoid using 99214 even when they should, out of fear of being audited. Most Medicare and commercial payer audits identify undercoding, not overcoding. Proper documentation—not the code itself—is what determines audit risk. Medicare’s own audit data shows that under-coding is far more common than over-coding, and it costs clinics thousands of dollars.Â
“Established Patient” Definition
Both CPT 99213 and 99214 apply to established patients, meaning the patient has received professional services from the provider or another provider of the same specialty within the past three years
Medical Decision Making: The Real-World Explanation (Not the Boring Version)
CMS defines Medical Decision Making using three elements: the number and complexity of problems addressed, the amount of data reviewed, and the risk of complications or morbidity.
Number and Complexity of Problems Addressed
This is the first—and often the most evident—difference between the two codes.
99213 Examples:
- A diabetic patient whose numbers look stable and needs medication refills.
- A teen with a mild sore throat and negative rapid strep.
- Anxiety follow-up where symptoms are under control and no treatment changes are needed.
The pattern?
One problem. Low severity. Nothing that makes you sweat.
99214 Examples:
- A hypertensive patient whose readings spiked over the past week, requiring medication adjustment and monitoring.
- A middle-aged patient showing mixed symptoms (fatigue, shortness of breath, dizziness), for whom you have to order labs to rule out anything serious.
- A person with diabetes whose A1c just jumped from 7.2 to 9.4 — clearly”ot stable”
In these situations, the condition is worsening, treatment may need to change, or you may need to evaluate multiple problems in one visit.
Data Reviewed and Analyzed (Labs, Tests, Notes, Imaging)
This is where providers often downcode without realizing it.
For 99213, you usually document:
- Reviewing recent labs already in the chart
- Maybe looking at vitals and the medication list
- No coordination with other providers
Pretty routine stuff.
For 99214, you’re typically doing one or more of the following:
- Ordering labs or imaging
- Reviewing 2+ external records
- Interpreting test results
- Communicating with another provider
- Changing treatment based on new data
Risk of Complications and Morbidity
This is the deal-breaker category—and the most misunderstood.
99213 risk looks like:
- Prescription refills
- Stable chronic issues
- Minor acute symptoms
- Over-the-counter or conservative management
- No change to existing treatment plans
99214 risk includes:
- Medication adjustments
- New prescriptions with side-effect risks
- Uncontrolled chronic disease
- Uncertain diagnosis
- Multiple comorbidities affect treatment
- Starting or changing psych meds
- Anything requiring close follow-up
If there’s even a chance of complications, third-party involvement, or escalation, then 99214 applies.
99213 vs 99214 in Psychiatry and Mental Health Visits
In psychiatry, 99214 is commonly appropriate when adjusting antidepressants, antipsychotics, mood stabilizers, or managing worsening anxiety, depression, or bipolar symptoms. Stable follow-ups without medication changes typically fall under 99213.
Using Time to Select 99213 vs 99214 (A Simple, Practical Breakdown)
Time matters only if you document it clearly.
Typical time ranges (varies slightly by payer):
- 99213: 20–29 minutes
- 99214: 30–39 minutes
But here’s the real secret:
Most clinics accidentally hit 99214 but don’t bill it because they forget to document counseling, reviewing history, patient education, coordination, or charting done on the same day.
If you spend 15 minutes with a patient but another 20 reviewing old charts, calling specialists, updating medication lists, and writing a note, that time counts.
Just document it properly.
Telehealth Billing Consideration
Telehealth visits may be billed using 99213 or 99214 as long as Medical Decision Making or total time requirements are met and documented, following Medicare and payer-specific telehealth policies.
Documentation Requirements: What Your Note Must Say for 99213 vs 99214
Most clinicians know the elements, but not how to phrase them.
For 99213, your note usually includes:
- HPI with 1–2 symptoms
- Brief exam (if relevant)
- A stable diagnosis
- No significant changes in the plan
- No new testing
- Minimal risk
- Straightforward or low MDM
If your plan says: “Continue current medication, return in 3 months, “you’re probably at 99213.
For 99214, your documentation should include:
- Multiple symptoms or conditions
- Any worsening of a chronic disease
- Medication changes
- New prescriptions
- Lab/imaging orders
- External notes reviewed
- Moderate MDM
- Clear “why” behind your decisions
Example of a 99214 plan: “P remains uncontrolled despite 3 weeks of adherence. We are increasing the dose, ordering CMP + BMP, and scheduling a 2-week follow-up. Patient counseled on risks of uncontrolled HTN.”
That kind of detail immediately signals moderate complexity.
Modifier -25 Reference
If a significant, separately identifiable procedure is performed on the same day as an E/M visit, modifier -25 may be required. Proper documentation must clearly support that the E/M service went beyond the procedural work.
Quick 99214 Documentation Checklist
- Worsening or multiple conditions
- Medication changes with reasoning
- Labs or imaging ordered or reviewed
- Moderate risk or uncertainty
- Clear clinical decision rationale
Common Mistakes That Lead to Underbilling or Denials (and How to Fix Them)
Clinicians lose thousands of dollars each year due to small, avoidable documentation and coding errors. Most of these mistakes happen in busy clinics where everyone is moving fast and trying to keep up. Here’s what usually goes wrong — and the simple fixes that keep money from slipping through the cracks.
Mistake #1: Treating Time and MDM as Two Separate Universes
Many providers feel pressured to choose MDM simply because it’s the “traditional” way. You don’t have to.
Fix: Pick whichever method (Time or MDM) gets you the correct code and is documented clearly. If the time supports 99214, use it. Don’t leave money behind.
Mistake #2: Coding Stable Chronic Conditions as Moderate Complexity
A stable chronic condition doesn’t magically become 99214 just because it’s chronic.
Fix: If the condition is stable with no changes, it usually fits 99213 — unless something else (like new symptoms, new testing, or a secondary problem) raises the complexity.
Mistake #3: Poor or Incomplete Documentation of Medication Changes
Writing “dose adjusted” or “increased meds” isn’t enough to support 99214.
Always document why you’re changing the medication and what the expected outcome is. Write a complete medical reasoning sentence, not a shorthand note that leaves room for interpretation.
Mistake #4: Forgetting to Document Data Review
Providers often spend time reviewing labs, imaging, external provider notes, or ER discharge summaries — but forget to document it in the chart.
Fix: A straightforward sentence, like “Reviewed cardiology note from 3/14; results impact today’s plan,” can legitimately move a visit from 99213 to 99214.
Mistake #5: Not Documenting Risk
Risk is one of the biggest drivers of 99214—and also the most frequently underdocumented.
Fix: If you start a new medication that requires monitoring, note it. If the patient’s condition is worsening, write it. These details clearly justify moderate MDM.
Downcoding vs Upcoding Explanation
Downcoding occurs when services qualify for 99214 but are billed as 99213, while upcoding involves billing a higher level without documentation support. Both can impact compliance and revenue.
Medicare vs commercial payer reimbursement scrutiny
While Medicare strictly follows CMS E/M guidelines, many commercial payers apply similar MDM standards with additional utilization review, making consistent documentation essential across all payers.
Reimbursement Differences: What You Actually Get Paid for 99213 vs 99214
These numbers vary by payer and state, but here’s the typical pattern:
| Code | Medicare (Average) | Commercial Payers (Average) |
| 99213 | $80–$95 | $95–$130 |
| 99214 | $120–$150 | $140–$210 |
Across thousands of claims, clinics see 30–40% higher payments for 99214 than for 99213.
If you under-code even 10 visits a week, that’s:
- 40 visits/month
- $35–$60 lost per visit
- $1,400–$2,400 is lost every month
Or around $20k–$30k a year.
Multiply that across multiple providers, and the losses become huge.
Coding 99213 vs 99214 doesn’t have to feel like walking through a minefield. Once you understand the flow — problem complexity, data review, and risk — the picture becomes clear. Most providers actually do the work that qualifies for 99214, but they forget to document it or under-code out of caution.
The result? Lower reimbursement, inconsistent revenue cycles, and constant second-guessing. That’s where strong billing support makes a massive difference.
Struggling to Code 99213 vs 99214 for Psychiatry Visits? We’ve Got You Covered.
Psychiatry and mental health visits frequently qualify for 99214, especially when managing medication adjustments, worsening symptoms, or complex treatment plans. Yet many providers undercode due to audit fears or unclear documentation standards.
At ANR Medical Billing, we specialize in psychiatry and mental health billing services. Our team ensures your E/M visits are coded accurately, supported by compliant documentation, and optimized for maximum legitimate reimbursement—without increasing audit risk.
From antidepressant and antipsychotic management to ongoing therapy and medication follow-ups, we help psychiatry practices:
- Correctly bill 99213 and 99214
- Reduce denials and downcoding
- Improve documentation consistency
- Capture revenue that’s often missed
Let our psychiatry billing experts handle the coding—so you can focus on patient care.
Contact ANR Medical Billing today to optimize your mental health revenue cycle.
FAQs: 99213 vs 99214 CPT Code
1. What is the main difference between CPT 99213 and 99214?
The primary difference between 99213 and 99214 is the level of Medical Decision Making (MDM) or total time spent on the date of service.
- 99213 represents low complexity visits
- 99214 represents moderate complexity visits
99214 is appropriate when conditions are worsening, medications are adjusted, additional data is reviewed, or clinical risk is higher.
2. Are 99213 and 99214 only for established patients?
Yes. CPT codes 99213 and 99214 apply only to established patients—patients who have received professional services from the provider or a provider of the same specialty within the past three years.
New patients must be billed using 99202–99205.
3. Does a medication change automatically qualify for 99214?
Not automatically—but most medication changes support 99214 when properly documented.
To qualify, the note must explain why the medication was changed, the clinical risk, and the expected outcome. Dose adjustments, new prescriptions, or medications requiring monitoring typically indicate moderate risk, supporting 99214.
4. Can stable chronic conditions be billed as 99214?
No. Stable chronic conditions without changes usually qualify for 99213, not 99214.
To bill 99214, the chronic condition must be worsening, uncontrolled, or require treatment modification, additional testing, or increased clinical risk.
5. How much time is required to bill 99213 vs 99214?
Typical time ranges (on the date of service) are:
- 99213: 20–29 minutes
- 99214: 30–39 minutes
Time includes face-to-face care, chart review, documentation, counseling, care coordination, and reviewing external records—as long as it’s documented.
6. Can 99214 be billed for telehealth visits?
Yes. 99214 can be billed for telehealth visits if Medical Decision Making or total time requirements are met and documented.
Telehealth visits follow the same E/M rules as in-person visits, subject to payer-specific telehealth policies.
7. Is 99214 more likely to be audited than 99213?
No. 99214 is not automatically a higher audit risk.
Audits focus on documentation quality, not the CPT code itself. In fact, Medicare audit data shows undercoding is more common than overcoding, leading to lost revenue rather than compliance risk.
8. Can 99214 be billed for mental health or psychiatry visits?
Yes. 99214 is commonly appropriate in psychiatry and mental health care, especially when:
- Adjusting psychotropic medications
- Managing worsening depression, anxiety, or bipolar symptoms
- Addressing medication side effects
- Treating multiple mental health conditions
Stable follow-ups without treatment changes usually qualify for 99213.
9. Does reviewing labs or external notes support 99214?
Yes. Reviewing labs, imaging, or external provider notes can support 99214 when it influences clinical decision-making.
The documentation should clearly state what was reviewed and how it impacted today’s treatment plan.
10. What documentation is required to support 99214?
To support 99214, documentation should include:
- Worsening or multiple conditions
- Medication changes with clinical reasoning
- Labs or imaging ordered or reviewed
- Moderate risk of complications or morbidity
- Clear explanation of medical decisions
The note must clearly explain why the visit required moderate complexity care.
11. Can modifier -25 be used with 99213 or 99214?
Yes. Modifier -25 may be appended when a significant, separately identifiable E/M service is performed on the same day as a procedure.
Documentation must clearly show that the E/M service went beyond the procedural work.
12. What happens if providers undercode 99214 as 99213?
Undercoding leads to:
- Lost revenue
- Lower visit value reporting
- Inaccurate provider productivity metrics
Many practices lose $20,000–$30,000 annually per provider due to consistent undercoding of 99214.
13. How do Medicare and commercial payers view 99214?
Both Medicare and commercial payers follow CMS E/M guidelines for MDM and time.
Commercial payers may apply additional utilization review, making clear documentation essential to avoid denials or downcoding.
14. What is the safest way to choose between 99213 and 99214?
The safest approach is to:
- Evaluate MDM first
- Use time when it better supports the visit
- Document clinical reasoning clearly
- Code what you actually did, not what feels “safer”
Proper documentation—not conservative coding—is what protects against audits.
15. How can a medical billing company help prevent undercoding?
A specialized medical billing company:
- Reviews E/M coding patterns
- Identifies undercoded visits
- Improves documentation habits
- Reduces denials and audit risk
- Increases legitimate reimbursement
This ensures providers are paid for the care the
