99214 CPT Code: Billing and Documentation Guide

Have you ever noticed why so many CPT 99214 claims are refused, especially when the visit appears routine? Healthcare providers, coders, and billing teams are often unable to identify whether their paperwork completely conforms to this widely used evaluation and management code. According to CMS 2025-2026 data, 99214 remains one of the most costly E/M codes, with improper payments totaling more than $560 million due to missing or insufficient documentation, incorrect MDM evaluation, or issues with time-based coding.

The benefit of using CPT 99214 correctly is that it effectively represents moderate-complexity treatment, allowing for fair reimbursement for evaluating several chronic illnesses, changing medications, and reviewing complex data. Medicare reimburses between $125 and $130 per visit, whereas commercial payers may pay up to 40% more, depending on the contract. Errors have major consequences, including denied claims, delayed payments, and increased audit scrutiny, which can disrupt revenue cycles and compliance efforts.

In this article, we will discuss the 2026 AMA and CMS standards for CPT 99214, covering medical decision-making vs time-based coding, telehealth documentation, typical billing errors, and practical scenarios, so your team can submit accurate claims with confidence and reduce audit risk.

What is the CPT 99214 Code?

CPT 99214 code is frequently used for established patient visits that involve moderate medical decision-making or a total provider time of 25–39 minutes. Correct use ensures compliance with the 2026 AMA and CMS E/M rules and reduces the risk of claim denials. This section explains its definition, purpose, and typical visit scenarios.

Definition and Purpose

CPT 99214 code represents an evaluation and management (E/M) service for established patients. It applies when a provider addresses moderately complex medical issues, reviews relevant data, and manages moderate risk in treatment decisions. The code can be chosen based on:

Medical Decision-Making (MDM): Managing multiple chronic or acute problems with moderate complexity.

Total Time: 25–39 minutes of direct and indirect patient care on the same date, including reviewing labs, counseling, ordering tests, and documenting.

Typical Visits for 99214

CPT 99214 code usually applies in outpatient settings where visits involve:

Multiple chronic conditions: e.g., diabetes with hypertension, COPD with heart failure.

Medication changes requiring monitoring: e.g., insulin adjustments, starting antidepressants.

New symptoms needing evaluation: e.g., chest pain, neurological deficits, or abdominal pain with warning signs.

CPT 99214 Code Description

This section explains how CPT 99214 is defined under the current AMA Evaluation and Management (E/M) rules. It focuses on decision-making, time use, and specialty-based applications to support compliant billing.

Medical Decision-Making (MDM)

Moderate MDM is the primary driver for CPT 99214 selection in most cases. Under 2026 AMA guidance, moderate MDM is met when two of three elements reach a moderate level:

1. Problems addressed

Two or more stable chronic conditions

One chronic condition with progression or side effects

One new problem with an uncertain outcome

2. Data reviewed

Review of lab trends

Review of external notes

Ordering or interpreting diagnostic tests

3. Risk of management

Prescription drug initiation or adjustment

Ongoing medication monitoring

Decisions that require follow-up due to patient risk

Time-Based Selection

Time may be used instead of MDM when total provider time reaches 25–39 minutes on the date of service. CMS confirms this applies across Medicare and most commercial payers in 2026.

Countable time includes:

Record review before the visit

Face-to-face or virtual evaluation

Counseling and care planning

Ordering tests or medications

Same-day documentation

Specialty Considerations

The use of CPT 99214 varies by specialty but follows the same general rules.

Common qualifying examples:

Primary care: Chronic disease management with medication changes

Cardiology: Review of diagnostic studies with treatment adjustment

Psychiatry: Medication modification with symptom monitoring

Retail clinics: Multiple conditions requiring prescription oversight

CPT 99214 Billing Guidelines

This section explains how to bill CPT 99214 correctly under 2026 payer rules. It focuses on modifiers, telehealth use, and errors that lead to denials.

Modifiers Used with 99214

Modifiers describe how and why a service was delivered. Incorrect use is a common auditing cause.

Modifier	When to Use	Documentation Requirement
25	When a significant E/M service is performed on the same day as a minor procedure	Separate and clearly identifiable evaluation beyond the procedure work
95	For real-time audio-video telehealth visits	Visit type, technology used, and moderate MDM or time support
24	During the postoperative period for an unrelated condition	Diagnosis and plan must be unrelated to the surgery
57	When the visit leads to a decision for major surgery	Clear documentation of the surgical decision made during the visit
93	For audio-only telehealth visits when permitted by the payer	Confirmation of audio-only format and payer approval
GT / GQ	Legacy telehealth modifiers required by select payers	Compliance with payer-specific telehealth policy

Telehealth Billing

CPT 99214 can be billed for telehealth if the visit meets moderate MDM or time criteria.

Key billing points:

Audio-video visits generally qualify.

Audio-only visits depend on payer rules.

Use POS 10 for the patient’s home.

Use POS 02 for other locations.

Document visit type, provider time, and patient consent.

Common Errors to Avoid

Errors often result from habit-based coding rather than documentation gaps.

Frequent issues include:

Using 99214 without showing moderate MDM or time

Missing time statements when billing by time

Incorrect POS or missing modifier 95

Linking assessment without a clear plan

Defaulting to 99214 for long visits without support

Conclusion

The proper application of CPT 99214 requires a clear alignment between documentation, medical decision-making, and time reporting. Applying the 2026 AMA and CMS rules consistently helps reduce denials, audit exposure, and payment delays.

When providers and billing teams apply these guidelines with discipline, CPT 99214 accurately reflects moderate-level care and supports stable reimbursement across payer types.