Reviewed November 9, 2026
CPT 99214 is an established-patient office visit that requires moderate medical decision making, or 30 minutes of total time on the date of the encounter when time is used to select the level. Payers most often downcode it to 99213 for one reason: the note shows neither two moderate MDM elements nor a documented total time that meets the threshold.
Each downcode costs $40.42 at the 2026 unadjusted Medicare rate (worked out below), and the pattern repeats on every note written the same way. The fix is not more documentation; it is documentation that shows the elements the AMA table counts, or a time entry that meets the descriptor.
What 99214 requires
The AMA’s CPT Assistant special edition (October 2024) prints the current descriptor: “Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded.”
Its Table 1 gives the rest of the established-patient family. 99212 requires straightforward MDM or 10 minutes, 99213 low MDM or 20 minutes, 99214 moderate MDM or 30 minutes, and 99215 high MDM or 40 minutes, with prolonged services code 99417 added to 99215 at 55 minutes or longer. 99211 is the clinical-staff visit and has no time threshold.
CMS’s Evaluation and Management Services booklet (MLN006764, May 2026) confirms Medicare follows the CPT MDM guidelines, that the history and exam must be medically appropriate but do not affect the level, and that when time is used “you must provide services for the full time.” The CPT midpoint rule for timed services does not apply, and the record must show the time as a start and stop time or a total.
Moderate MDM: two of three elements
The AMA’s 2023 E/M guidelines document (effective 1 January 2023) states that to qualify for a level of MDM, two of the three elements for that level must be met or exceeded. Table 1 defines the moderate row:
| Element | What qualifies as moderate |
|---|---|
| Problems addressed | 1 or more chronic illnesses with exacerbation, progression or side effects of treatment; or 2 or more stable chronic illnesses; or 1 undiagnosed new problem with uncertain prognosis; or 1 acute illness with systemic symptoms; or 1 acute, complicated injury |
| Data reviewed and analyzed | At least 1 of 3 categories. Category 1: any combination of 3 from review of prior external notes from each unique source, review of the result of each unique test, ordering of each unique test, assessment requiring an independent historian. Category 2: independent interpretation of a test performed by another physician. Category 3: discussion of management or test interpretation with an external physician or appropriate source |
| Risk of patient management | Moderate risk of morbidity from additional diagnostic testing or treatment. The table’s examples are prescription drug management, a decision about minor surgery with identified risk factors, a decision about elective major surgery without identified risk factors, and diagnosis or treatment significantly limited by social determinants of health |
A common path to 99214 is problems plus risk: two stable chronic illnesses managed with prescription drugs, or one worsening chronic illness with a medication change.
Where the note loses the level
The AMA definitions behind Table 1 are where reviewers find the gaps.
- “Stable” is defined by the treatment goal, not by change. The guidelines say a patient who is not at his or her treatment goal is not stable, even if the condition has not changed and there is no short-term threat to life or function. A note that calls that patient “stable” has understated the problem element.
- A problem counts only if it is addressed. A problem is addressed when it is evaluated or treated at the encounter. A notation that another professional is managing it, without additional assessment or care coordination, does not qualify. A referral without evaluation does not qualify. Comorbidities are not counted unless they are addressed.
- Tests are counted by unique test, and ordered means reviewed. A clinical laboratory panel such as a basic metabolic panel is a single test. Tests ordered at an encounter are presumed analyzed when the results are reported, so they count in the encounter in which they were ordered, not again when the result comes back. A service whose professional component the same clinician reports separately, such as an in-office EKG interpretation, is not counted as data at all.
- Independent historian and discussion have definitions. An independent historian provides a history because the patient cannot give a reliable one; translation services do not count. A discussion must be an interactive exchange with an external physician or appropriate source, not chart notes passed through staff.
- Risk is about the management decision. The guidelines say risk relates to the consequences of the problems addressed when appropriately treated, including the decision to initiate or forgo testing, treatment or hospitalization. “Prescription drug management” is the AMA’s own moderate-risk example, and the note has to show the management: the drug started, continued, adjusted or stopped, as a decision made at that visit.
When time is the better route
The AMA guidelines define total time as the face-to-face and non-face-to-face time personally spent by the physician or other qualified health care professional on the date of the encounter. It includes preparing to see the patient, the examination, counseling, ordering medications, tests or procedures, documenting in the record, independently interpreting and communicating results, and care coordination. It excludes activities normally performed by clinical staff, other separately reported services, travel and general teaching. A visit that ran 32 minutes of physician time, including the charting completed that evening, is a 99214 on time even if the MDM is low.
For split or shared visits, CMS’s booklet requires modifier FS on a split or shared claim and defines the substantive portion for office visits as more than 50 percent of total time or a substantive part of the MDM.
Prolonged time does not attach to 99214. CPT places 99417 with 99215 at 55 minutes or longer, and CMS’s booklet lists G2212 in addition to 99205, 99215 or 99483, with Table 3 starting G2212 at 69 minutes with 99215.
What a downcode costs
CMS’s relative value file released 26 August 2026 (RVU26D) gives 99213 a 2026 non-facility total of 2.85 RVUs and 99214 a total of 4.06. At the 33.4009 conversion factor that is $95.19 against $135.61 before geographic adjustment, a difference of $40.42 per visit.
The 99214 pre-bill check
- The assessment names each problem addressed and its status in the AMA’s terms: at goal or not at goal, worsening, new with uncertain prognosis, systemic symptoms.
- At least two moderate elements are visible on the face of the note, usually problems and risk.
- Each medication decision is written as a decision, not a list.
- Data entries name the unique test or the unique external source; a panel is one test.
- If time is the basis, the entry is physician or qualified-professional total time for the calendar date, and it meets 30 minutes.
- Nothing counted toward MDM or time was also billed as a separate service, and split or shared visits carry modifier FS.
Our post on AWV billing with modifier 25 covers the problem-visit-plus-wellness-visit day, and the internal medicine CPT cheat sheet and other quick-references live in the AMS resources library. When a practice’s level-4 claims keep paying at level 3, AMS Solutions, billing for practices since 1992, reads the notes against the AMA table before the payer does as part of our internal medicine billing services.
