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99213 vs 99214: Medical Decision Making & Time Guidelines

Last Updated: July 16, 2026

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).

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2026 Medicare National Fee (99213): Non-Facility (Office): $117.58 · Facility (Hospital): $64.37
✓ 111 Medicare-Approved ICD-10 Diagnoses on file for 99213:

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. 1 or more chronic illnesses with exacerbation, progression, or side effects of treatment, OR 2 or more stable chronic illnesses.
  2. Prescription drug management.

NCCI Edits

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Not sure if these codes bundle? Check the latest Medicare NCCI database updates before you bill.

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.

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