In the office or clinic setting, a level 4 established patient office visit (CPT 99214) has always been the Evaluation and Management (E&M) code most physicians and nonphysician practitioners are cautious about billing to avoid payer scrutiny, yet they appreciate when they can bill it because the reimbursement is fair. This is probably because E&M documentation (and coding in general) continues to be a confusing maze to navigate, and errors are fairly common, regardless of the E&M code set.
The CERT (Comprehensive Error Rate Testing) contractor’s most recent data analysis pertaining to E&M services indicates that code 99214 has been overused compared with other E&M Current Procedural Terminology service codes. The errors identified for 99214 include inappropriate use of high-level E&M codes that were down-coded to a lower level of service, no medical documentation submitted for the date of service billed, and insufficient documentation to support the code.
As a reminder, code 99214 requires 2 of the following 3 key components: detailed history, detailed exam, and moderately complex medical decision-making. According to Current Procedural Terminology, the patient’s presenting problems must be of moderate to high severity.