CPT 99214: established patient office visit, moderate decision making
99214 reports an office or other outpatient visit for an established patient when the medical decision making is moderate, or when the practitioner's total time on the date reaches 30 minutes. Its distinguishing feature is that Medicare gives it no prolonged-service option.
Written by Salman Saeed, CEO and Co-Founder · Reviewed by a Certified Medical Coder · Last reviewed October 2026In short: 99214 is the moderate-level established office visit, supported by moderate decision making or 30 minutes of total time. It has no prolonged-service option, because Medicare allows G2212 only above 99215, so extra minutes either lift the visit to 99215 or add nothing.
What does CPT 99214 report?
99214 is an E/M code for an established patient seen in an office or other outpatient setting, one step above 99213. It needs a medically appropriate history and exam, and the level comes from moderate MDM or from time. CMS labels it "Office o/p est mod 30 min" in its fee schedule file.
| Item | Value in the file |
|---|---|
| Payment status | A (active code) |
| Work RVU | 1.92 |
| Non-facility total RVU | 4.06 |
| Facility total RVU | 2.53 |
| Global period | XXX |
| MUE value and indicator | 2, with indicator 3 (date of service edit, clinical data) |
Does time or MDM set the level for 99214?
Either one can. Chapter 12 of the Medicare Claims Processing Manual says that since January 1, 2023, office visits are leveled by MDM or by total time, and history and exam no longer count toward the level. The practitioner reports the method that supports the higher defensible code.
- By time: the note carries total minutes for the date, or a start and stop time. Thirty minutes must be fully met. Chapter 12 and MLN006764 both say the CPT midpoint rule does not apply, so 29 minutes is 99213.
- By MDM: the note supports moderate decision making under the AMA E/M guidelines, which MLN006764 names as the source for the MDM elements.
- Reviewers test time-based visits. Chapter 12 section 30.6.7 F says medical reviewers use the record to check medical necessity and the accuracy of the time recorded.
How do I level a visit with one new problem and one chronic problem?
Count what was addressed and decided that day, then check the three elements the AMA guidelines use. The CY 2024 final rule describes them as the number and complexity of problems addressed, the data reviewed and analyzed, and the risk of the patient's management. Under the CPT approach quoted there, two of the three must reach the level.
The AMA table sets each level and CMS does not reprint it, so check the note against that table, not against the number of diagnoses. Chapter 12 says the volume of documentation should not be the main influence on the code.
Why is there no prolonged add-on for 99214?
Prolonged office service G2212 is reported only after the time for the highest level is passed. Chapter 12, section 30.6.15.2, ties G2212 to 99205 and 99215 and shows 99215 alone at 40 to 54 minutes. A 50 minute visit billed by time is therefore 99215, not 99214 with an add-on.
How does 99214 work with dialysis and other same-day services?
It follows modifier 25 rules. The NCCI Policy Manual, Chapter XI, lets an office visit such as 99214 be reported on a dialysis date, with modifier 25, only for a significant, separately identifiable service unrelated to the dialysis and renal failure. Visits for hypertension, fluid overload, uremia or electrolyte imbalance are not separately reportable. See 90935 and modifier 25.
The Medicare same-day rule applies too. Chapter 12 section 30.6.7 B pays two office visits on one date only when the note shows unrelated problems that could not be handled in one encounter.
How does 99214 appear on the claim?
On the CMS-1500, 99214 goes in Item 24D with 1 unit in Item 24G and the place of service in Item 24B, with modifier 25 in Item 24D when a procedure shares the date. The NCCI practitioner MUE table effective October 1, 2026 lists 99214 at 2 with adjudication indicator 3. G2211 uses 99214 as its base code, and is not paid when 99214 carries modifier 25 unless the other service that day is a Part B preventive service, a vaccine administration or an annual wellness visit.
What goes in Items 24D, 24E and 24G for 99214?
On the professional claim, 99214 sits in Item 24D with up to four modifiers, and Chapter 26 lets the form carry that many. When a procedure shares the date, modifier 25 rides on the visit line, not on the procedure. Item 24E takes a single pointer letter, so choose the diagnosis that best carries the moderate problem load.
The CMS file shows 99214 with status A and global XXX. The practitioner MUE table allows 2 per date, but billing two moderate visits for one patient on one day invites a duplicate review, so the chart must show why a second encounter happened.
Example: A patient returns on 10/20 for hypertension that is not at goal and a new rash. The note records two problems and a medication change. The line reads 99214, pointer A (I10), 1 unit, $176.00. A wart removal the same day goes on its own line, and 25 is added to the 99214 line only. Leaving 25 off draws CO-97, the visit folded into the procedure, not a payment.
Why is 99214 denied or downcoded?
| Code | What X12 says | What usually causes it |
|---|---|---|
| CO-150 | The information submitted does not support this level of service | Downcoded to 99213 because the note shows low problems or under 30 minutes |
| CO-50 | Non-covered because the payer does not deem it medically necessary | A visit with no clear reason in the assessment |
| CO-97 | The benefit is included in the payment for another service already adjudicated | The visit was bundled into a same-day procedure without modifier 25 |
| CO-11 | The diagnosis is inconsistent with the procedure | Diagnosis pointers that do not match the visit |
If these denials keep coming back, our denial management team can work them. See also nephrology billing, internal medicine billing, family medicine billing and infectious disease billing.
Related codes
- Physician Fee Schedule relative value files, RVU26D (October 2026) · CMS
- Medicare NCCI Medically Unlikely Edits, practitioner services table, effective 10-01-2026 · CMS
- Medicare Claims Processing Manual, Chapter 12: Physicians/Nonphysician Practitioners · CMS
- Evaluation and Management Services (MLN006764, May 2026) · CMS
- 2026 NCCI Medicare Policy Manual, Chapter XI: Medicine and Evaluation and Management Services · CMS
- CY 2024 Physician Fee Schedule final rule (88 FR 78818) · Federal Register
- FAQs about the E/M visit complexity add-on HCPCS code G2211 · CMS
- Claim Adjustment Reason Codes · X12
- Medicare Claims Processing Manual, Chapter 26: Completing and Processing Form CMS-1500 Data Set · CMS
We check every rule, code and deadline against the official source. See our editorial policy.
Common questions
Straight answers from the team that does the work.
Ask a billing lead directly. A 20-minute call, Monday to Friday, 9am to 5pm Eastern.
01Does time or MDM set the level for 99214?
Either can. CMS lets practitioners pick MDM or total time for office visits since January 1, 2023. Time needs a full 30 minutes on the date of the visit, with no midpoint rounding. MDM needs moderate decision making under the AMA guidelines. Choose the method the note supports best.
02How do I level a visit with one new and one chronic problem?
Score the three AMA elements: problems addressed, data reviewed, and management risk. Two of the three must reach moderate for 99214. A new problem plus a chronic condition can support moderate problems, but data and risk still decide. Diagnosis count alone does not set the level.
03How many minutes does 99214 require?
Thirty minutes of total practitioner time on the date of the visit, met or exceeded. CMS states the CPT midpoint rule does not apply, so 29 minutes does not support 99214. Record total time or a start and stop time, because reviewers check time-based visits.
04Can I bill G2211 with 99214?
Yes, when the practitioner is the continuing focal point for the patient's care or gives ongoing care for a serious or complex condition. 99214 is a base code. G2211 is denied if 99214 carries modifier 25, except on days with a preventive service, vaccine administration or annual wellness visit.
05Is there a prolonged service code for 99214?
No. Medicare's prolonged office add-on G2212 attaches to 99215 once its time is exceeded, per Chapter 12 section 30.6.15.2. A visit that runs past the 99214 label on time moves up to 99215 at 40 minutes. It does not add an extension to 99214.
06What is the NCCI MUE for 99214?
The practitioner MUE table effective October 1, 2026 lists 99214 at 2 units per date of service with adjudication indicator 3, a date of service edit based on clinical data. The Medicare same-day visit rule in Chapter 12 still limits payment for repeat visits by one group.
Moderate visits downcoded to low?
We check the time or MDM behind each 99214 and appeal downcodes with the note in hand.