The line between billing a 99213 (Low Complexity) and a 99214 (Moderate Complexity) is where millions of dollars in revenue are lost due to provider under-coding. Following the updated AMA guidelines, you can bill based on either Time OR Medical Decision Making (MDM).
Time-Based Billing Guidelines
If billing based on total time spent on the date of encounter (including face-to-face and non-face-to-face time):
- 99213: 20 - 29 minutes
- 99214: 30 - 39 minutes
Medical Decision Making (MDM) Rules
To bill 99214 based on MDM, you must meet 2 of the 3 elements for "Moderate" complexity:
- 1 or more chronic illnesses with exacerbation, progression, or side effects of treatment, OR 2 or more stable chronic illnesses.
- Prescription drug management.
NCCI Edits
When billing 99213 or 99214 with a procedure, Modifier 25 is required. Always run an NCCI check to ensure the procedure code does not have an indicator that prohibits separate E/M billing.