Level 4 office-visit coding

January 31, 2013

Many pediatricians are downright timid when coding our acute care notes for established patients. To upgrade your practice to v2.0, you need to maximize practice revenue by optimizing coding of visits so you can derive all appropriate charges per visit.

In my experience, insurance companies pay $50 to $60 more for a 99214 than for a 99213 visit. Once you understand the basics, little effort is required to correctly code and document a 99214 office visit and pass the inevitable insurance company audit of your patient charts.

Ignorance is not bliss

Unfortunately, there are few among us who were correctly taught to code in medical school or residency. Although there are only a handful of studies looking at how well physicians code for office visits, all conclude that physicians undercode their established patient office visits.1-4

The most recent study examined the notes from 351 senior resident family physicians in 2 programs in Tennessee.5 Expert coders found that 33% of visits were undercoded based on the documentation; 50% were undercoded based on the medical decision making; and 80% of the visits were undercoded based on the number of presenting problems.

It is worth your time to take a course in office coding. It is a minimal investment that will reap huge benefits in terms of practice revenue. For pediatricians who don’t have the time to attend a formal course, I recommend an online coding course for physicians at EMuniversity.com. It is inexpensive and has wonderful video tutorials and an active forum, with myriad examples of coded notes for providers to review.

Pediatricians who conservatively code their visits need to understand that it is illegal to overcode or undercode for an office visit. Coding must be done correctly for each and every visit, and our only justification for our level of services is the office note.

Common procedural terminology (CPT) codes were established by the Centers for Medicare and Medicaid Services (CMS), which has issued guidelines regarding office documentation. Two versions of these guidelines have been published, in 1995 and 1997, and most coders feel that the 1995 guidelines are the most appropriate for primary care physicians. For our purposes, I’ll discuss the documentation requirements per the 1995 guidelines.


Many of us were taught to use subjective, objective, assessment, and plan (SOAP) notes for charting patient visits. Although SOAP notes get the job done, these will not be adequate for documenting most office visits, unless you assign time duration for all your notes. If you use paper charts, I recommend that you use preprinted encounter notes with check boxes to facilitate entering the elements of the visit we will discuss shortly. It is a better idea to invest in an electronic health care record (EHR), which gives you the ability to use templates for acute visit notes that automatically include the patient’s problem list, allergies, and medication list.

There are a number of myths that surround coding of established patient low-complexity (CPT 99213) and moderate-complexity (CPT 99214) visits. In primary care, CMS has suggested that the 99213 visit should be the most common code used, with 99214 visits representing roughly a third of the number of 99213 coded.

In reality, the office visit code is based on a number of factors, foremost of which are the nature of the presenting problem and the number of problems addressed at the visit. Physicians need not concern themselves with the number of  99213 and 99214 visits that are submitted to insurance carriers, as long as visits are documented correctly to support the level of visit billed.

Other misconceptions are that writing a prescription or ordering an x-ray or lab test automatically qualifies a visit for a 99214 level visit.

Elements of style

In grammar school we were taught that there are components of a sentence. This is true of the properly written office note that will document appropriate care as well as a correctly coded visit. These elements are 1) the history; 2) the physical exam; and last, 3) medical decision making. CMS only requires correct documentation of 2 of these 3 elements to code for a 99214 visit (Table 1).6

To document the history sufficient for a 99214 visit, your history should include the chief complaint; the history of the present illness (HPI); the past medical, family, and social history (PFSH); and the review of systems (ROS).

The HPI should include at least 4 of the descriptive elements of the presenting problem (let’s say ear pain): location (eg, left ear); duration (eg, 3 days); quality (eg, burning or stinging); timing (eg, intermittent or constant); severity (7/10 on pain scale); and context (eg, associated with upper respiratory infection symptoms), including any modifying factors (eg, improved with ibuprofen) or any associated signs or symptoms (eg, fever, vomiting). This can easily be accomplished with a few short sentences per problem. For example: “Patient presents with dull ache in left ear x 3 days.” “Patient reports pain is 7/10 in severity, constant, improves with ibuprofen, and is associated with vomiting and temperature to 102” (Figure 1).

A level 99214 visit history also requires 1 of 3 elements for PFSH that is pertinent to the presenting problem. A statement of drug allergies, list of medications, or exposure to ill persons is usually sufficient to satisfy this requirement.

Last, 2 or more pertinent elements of ROS should be documented to satisfy the history component of the 99214 visit. That’s it. These 99214 histories are easy to document, and in the context of continuity of care less is often more.

Documenting the physical exam component of the 99214 visit is similarly accomplished with ease, and according to the 1995 guidelines, requires examination of just 5 to 7 systems, including the patient’s vital signs.

Medical decision making

The most complicated piece of coding an office visit is to determine the medical decision making (MDM) involved. MDM is the component that attempts to reward value for our cognitive abilities. CMS recognizes 4 types of medical decision making (straightforward, low complexity, moderate complexity, and high complexity; Table 2).6 MDM quantifies the complexity of establishing a diagnosis and/or selecting a management option by measuring:

•   Nature of presenting problem (the number of possible diagnoses and/or the number of management options that must be considered).

•   Data reviewed (the amount of medical records, diagnostic tests, and/or other information that must be obtained, reviewed, and analyzed).

•   The risk of significant complications, morbidity, and/or mortality associated with the patient’s presenting problem(s), the diagnostic procedure(s), and/or the possible management options.

The MDM requirement of documenting an office visit is confusing and even frustrating at first look. Fear not, because with a little coaching and practice, you’ll become proficient at documenting appropriate levels of MDM for all your visits. Remember that the 99214 visit requires moderate MDM, which in turn requires adequate “passing scores” relating to 2 of the 3 components above-risk, the amount of data reviewed, and the nature of the presenting problem. To decide on a level of MDM, you need to keep a coding sheet handy (Figure 2).6 To bill for moderate MDM, your documentation must achieve at least 2 of the 3 criteria on the coding sheet: 1) 3 problem points or higher; 2) 3 data points or higher; and 3) be listed under moderate risk in the risk table.

The best approach to an established patient visit is to determine the level of risk at the time of the patient visit by assigning the highest applicable level of risk in the risk table. You can see from the table that in pediatric practice the most common problems that qualify as moderate risk are those patients who present with:

•   One or more chronic illnesses with mild exacerbation, progression, or side effects of treatment (asthma exacerbation, attention-deficit/hyperactivity disorder [ADHD] not responding to medication).

•   Two or more stable chronic illnesses (asthma, enuresis).

•   Undiagnosed new problem with uncertain prognosis (eg, blood in the stool).

•   Acute illness with systemic symptoms (eg, pyelonephritis, pneumonitis, colitis).

•   Acute complicated injury (eg, head injury with brief loss of consciousness).

•   Conditions that require prescription drug management.

If a patient falls into the moderate risk category, then determine the number of problems addressed at the visit as well as the data reviewed and assign a point value to this information using the coding sheet. Remember that 3 or more problem points or 3 or more data points are needed to qualify a visit as a 99214 level, as long as the problem or problems fall into the moderate risk level. If you determine your visit should be assigned moderate MDM, make sure you document the necessary elements for the history and/or the physical exam to qualify your visit as a 99214 visit.

Time is on your side, but . . .

Remember that if you document that you spent 25 minutes with a patient, with 13 or more minutes spent in counseling, and detail your discussion, then your visit automatically qualifies as a 99214 visit. Keep in mind that pediatricians are not specialists, and although the time we spend with some complicated patients may seem never ending, you need to time your visits accurately. Shrewd insurance company auditors know you can only see two 99214 visits per hour with time-based billing, but there are no such time limitations when you use the documentation approach discussed above to document your 99214 visit.

Implications for pediatricians

You should consider writing 99214 visit notes for ill patients with pneumonia, bronchiolitis, asthma, strep pharyngitis, and otitis media, to name a few. Also consider 99214 notes for patients that you investigate for fatigue, abdominal pain, and chest pain or for those patients with ADHD with whom you initiate medication. There are lots of grey areas in coding, and if there is any question regarding the correct code for visit, I suggest you err on the side of coding conservatively, unless your visit will qualify based on time coding. 


1. King MS, Sharp L, Lipsky MS. Accuracy of CPT evaluation and management coding by family physicians. J Am Board Fam Pract. 2001;14(3):184-192.

2. Kikano GE, Goodwin MA, Stange KC. Evaluation and management services. A comparison of medical record documentation with actual billing in community family practice. Arch Fam Med. 2000;9(1):68 -71.

3. Chao J, Gillanders WG, Flocke SA, Goodwin MA, Kikano GE, Stange KC. Billing for physician services: a comparison of actual billing with CPT codes assigned by direct observation. J Fam Pract. 1998;47(1):28-32.

4. King MS, Lipsky MS, Sharp L. Expert agreement in current procedural terminology evaluation and management coding. Arch Intern Med. 2002;162(3):316-320.

5. Holt J, Warsy A, Wright P. Medical decision making: guide to improved CPT coding. South Med J. 2010;103(4):316-322.

6. Department of Health and Human Services. Centers for Medicare and Medicaid Services. Evaluation and Management Services Guide. Baltimore, MD: Centers for Medicare and Medicaid Services; 2010.