Required documentation for 99214 coding

February 5, 2019

In order to justify the Level 4 E/M visit, make sure you have recorded all necessary information-and clearly label it for the payer auditor to easily find.

Q: A payer has questioned my coding for an office visit as a 99214. I saw the patient following an emergency room (ER) visit for uncontrolled hypertension. I documented her urgent care and ER visit dates, noted blood pressure results at the acute care facility, and medication recommendations by these facilities. Medical decision-making (MDM) clearly states that there must be documentation of at least one chronic mild and/or self-limited problems with ongoing activity/active problem and mild to moderate exacerbation with regard to risk. Data also had to be obtained and reviewed from the urgent care and ER, visits that were on two separate days. Medications were managed and adjusted: Lisinopril was stopped and HCT was advised for patient to continue. Why isn’t the above information sufficient for a 99214 code?

A: I reviewed the note you sent. As you correctly stated, the assessment and plan clearly indicates the “exacerbated, progressing, worsening” nature of the hypertension is associated with moderate level decision-making on table 3, or table of risk, for an established CPT code 99214.

There are three decision-making tables. To and to attain a given level of decision-making, you need to have two of the three. I say this because you allude to the second table, the data table, in your e-mail with reference to obtaining data and reviewing records. However, this isn't documented in the note. You allude to some of that history in the history of present illness (HPI) section, but there is no reference to review and summary of old or other records.

From a quantitative perspective, what we are left with here is one worsening established problem on table 1, and a corresponding either worsening or systemic problem on table 3. The first table scores two points, or low MDM, and the second scores three points, or moderate MDM.

One could infer that you read something or sourced it somewhere. It's too precise for it to have come from the patient, I think, but you can’t expect a payer auditor to do that. It is unlikely that a regulator would “assume” your record review and give you decision-making points for it-especially since the text you reference is in the HPI.

They are actually looking for a header or label that states “Review and Summary of Old Records.” That’s usually further down after the exam under the review of old CT scans.

There is no reason the review and summary can't be up moved up or even included in the HPI. To get MDM credit for it, you'd be better off labeling it as I suggest above. Think you’ll miss this when it goes away in 2021?


Q: One of our providers billed a 99173 and it hit my edits as having an unbundle relationship with a 99214 billed on the same date. Do you know if this is billable code? The 99214 has a modifier 25 attached to it.

These codes do appear linked in the National Correct Coding Initiative edits but can be broken with a modifier 59 on the 99173.

Bill Dacey, MHA/MBA, CPC is principal in The Dacey Group, Inc., a consulting firm dedicated to coding, billing, documentation, and compliance concerns for physicians. Dacey is a AAPC-certified coding instructor and has been active in physician training for more than 25 years. He can be reached at