A 99214 should have EITHER
1) a “detailed” history, consisting of all of the following:
a) 4 or more elements in the HPI
b) at least 2 systems included in the ROS
c) one item from the PMH, FH, or SH. OR
2) an exam consisting of 2 or more bullets in 9 or more organ systems.
In general, it is fairly easy to get a detailed history. Four elements in the HPI (location of pain, intensity, duration, frequency, quality, modifying factors, etc.) is not difficult. “Constant burning pain in throat for 3 days” would qualify. “Pt. is a teacher with a FH of HTN” would qualify for the FPS history. The ROS must be included, but there are ways to speed up the ROS process. Personally, I try to do a detailed history on all of my patients, because it is easy to do. Most patients tell you a detailed history whether or not you want to hear it, so you might as well document it.
A 99214 should also have (in addition to the above) moderate-complexity decision making. To have moderate complexity of decision making, you should document 1 and 2 below:
1) a new problem addressed (newly diagnosed hypertension) OR two or more old problems addressed where at least one is worsening (hypertension, stable, and hyperlipidemia, worse)
2) moderate risk. Any one of the following:
a) Two or more chronic stable illnesses addressed
b) One chronic illness that is worsening
c) A new problem with uncertain prognosis (not otitis media)
d) A prescription drug written
(Note that new problems described above should generally not include problems that are considered “self-limiting or minor,” that patients could have been treated at home on their own, such as a simple insect bite or URI.)
Although the above is fairly detailed (we could get much more detailed if you like), we can quickly boil down a 99214 to a few key items that distinguish it from a 99213. If you document the following, your visit will qualify for a 99214:
- document 4 elements in the HPI
- a ROS
- 2 elements from the family-psychosocial history
- a new problem, worsening chronic condition, or two or more chronic problems addressed
- prescription drug management.
If one makes a habit of always getting a detailed history (4 elements in the HPI, 2 in the FSH, and a ROS), then your decision between a 99214 and a 99213 becomes quite easy.
1. Did you document a new problem (cellulitis), a worsening old problem (COPD, worsening), OR address 2 old problems (HTN, stable and hyperlipidemia, stable).
2. Did you write a prescription?
If the answer to both of these question is yes, then you qualify for a 99214. If not, then you almost certainly qualify for a 99213.
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