What are the codes, who can bill for them and what are the differences between the two?

Both of these CPT (Current Procedural Terminology) Codes are part of a particular family of billing codes, including 99211-99215. They are part of HCPS, the Healthcare Common Procedure Coding System. They are used for office visits with established patients being treated for medical and mental health conditions.

While these two codes are within the same family, they do have different regulations for reimbursement. Due to some of their similarities, many healthcare providers can experience confusion when deciding which one to bill.  The fact that one code provides for additional revenue/reimbursement makes it critically important to thoroughly understood the differences. This way, all clinicians billing with these codes can receive the highest reimbursement for their services.  This being said, providers must be sure that the treatment being offered accurately represents the services required for billing with such a code

Some providers bill with CPT Code 99214 all the time. Others are afraid that they won’t be reimbursed for it. Once you know the ins and outs of both codes, choosing which one to bill is actually quite simple. To avoid any pitfalls, let’s take a closer look at each code and how it can be used for reimbursement.

What exactly are CPT Codes 99213 and 99214?

CPT Code 99213 can be utilized for a mid-level outpatient or inpatient office visit. CPT Code 99213 is a level three code that should be used for an established patient. It cannot be used with a new patient who has no history. However, this code is extremely popular, being the second most used among middle level billing codes. This is due, in part, to more easily achieved factors for reimbursement on this code than with other CPT Codes, including 99214.

CPT Code 99214 can be used as part of the second highest level in care for a patient’s visit. CPT Code 99214 is a level four code that can be used only for an established patient, whether the visit is conducted in the office or in an outpatient atmosphere. Therefore, it is no surprise that CPT Code 99214 is used the most frequently for this form of visit. It offers higher revenue/reimbursement than some similar CPT codes, including CPT Code 99213. This has especially been the case since changes were made back in 2013,  along with the Affordable Care Act’s inclusion of mental healthcare in 2006.

Who can bill with CPT Codes 99213 and 99214?

Many medical professionals can bill with CPT Codes 99213 and 96214. The good news is that it is not only for mental health providers or therapists. Behavioral health assessments can be very important tools in the most common of healthcare environments. For example, they can be used in primary care or OB/GYN offices.

An easy-to-understand example of a physician using CPT Code 99213 is when an existing patient has a scheduled appointment for a routine health examination. This patient may have had mild back pain for three or four years, being treated with muscle relaxants. When the pain occurs, the patient may also experience anxiety, which is being treated with a low-dose anxiolytic medication. There are no new diagnosis or medications prescribed. However, behavioral assessment tools may be utilized to ensure that the anxiety is still at a mid-level, with no additional risk factors.

A great example of a primary care doctor using CPT Code 99214 is when an existing patient comes in for a routine health examination for chronic pain. However, the flow of conversation may quickly turn to feelings of depression that are now accompanying this pain. The physician may choose to prescribe a medication for the patient’s behavioral health ailment. In more severe cases, perhaps even a referral may be set in motion for a mental health professional. Standardized assessment tools for depression (e.g. PHQ-9) may also be used to gather more detailed information.

What procedures are there for billing CPT Code 99213?

Understanding the conditions that must be present for billing with CPT Code 99213 is pretty straightforward. There must be two out of three of the following components:

  • An expanded problem-focused history
  • An expanded problem-focused examination
  • Medical decision-making with low complexity

Any mix of these three components will enable a provider to bill with CPT Code 99213. However, there must be a sum of at least 15 minutes of face-to-face time with the patient. The problems are typically considered to be of low to moderate severity.

What procedures are there for billing CPT Code 99214?

This is actually the simplest part of billing with CPT Code 99214. There must be two out of three factors included for proper billing of Code 99214. These necessary components include:

  • A detailed interval history
  • A detailed examination
  • Medical decision-making that can be considered to be of moderate complexity

Any mixture of these components necessary to bill for CPT Code 99214 should be presented in face-to-face time with the patient, totaling 25 minutes. The problems are usually of a moderate to high complexity.

How Do You Meet These Components?

While the detailed or expanded exams are fairly commonplace, as well as easily achieved, most of the questions come in regarding the history and decision-making components. However, these may also be carried out and documented in far less complex methods than originally anticipated.

The detailed or expanded history can be simply derived from past charts of the existing patient. However, it can also be even more easily collected through assessments that are filled out in the waiting room. A good example of this is the utilization of mental health assessment tools to investigate the possibility of mental illness as a possible attributing factor to a health problem.

Also keep in mind that decision making does not always need to include detailed exams. It can most commonly be achieved when a consultation with a specialist (e.g. a psychologist or a psychiatrist) is required. With 99214 , it is possible when there has been a new diagnosis (e.g. depression or anxiety), requiring further testing or a new medication prescription.

How often can testing be billed with CPT Codes 99213 and 99214?

CPT Codes 99213 and 99214 may be billed in time-derived methods for each patient during each session where the guidelines for billing are met. Healthcare providers will be able to provide a higher level of care for their patients by discovering mental health issues. 

Where can I find standardized screening instruments to use with CPT Codes 99213 or 99214 for behavioral assessments?

Mentegram has a library full of online tools, such as the PHQ-9, that range from detailed surveys to simple sliding scales. They can be used to increase the complexity of visits and thereby qualify for billing with a higher code (e.g. billing CPT Code 99214 instead of 99213). Mental healthcare providers may also use these tools to help reduce and even replace paperwork. This can save valuable time in patient intake and with screening the patients and monitoring their progression, even in between appointments.

What are the most important things to remember about differentiating between CPT Codes 99213 and 99214?

  1. Be sure to remember the difference in the components that must be present to bill for each code.
  2. Make sure that medical necessity is the driving factor to determine if low-level or moderate-level care is given.
  3. Ensure that your documentation also supports the level of care that is being billed.

Ask us how you can start billing with CPT Codes 99213 and 99214, as well as with other codes today!

For more information on other ways to bill and increase your practice’s revenue, check out our articles on CPT Code 96127 and CPT Code 96103:

CPT Code 96127 – Answers to the frequently asked questions about billing this code

3 Online Screenings That Can Be Billed with CPT Code 96127

CPT Code 96127 – How to Increase Revenue with This New Behavioral or Emotional Assessment

CPT Code 96103: How to Increase Revenue and Bill with Psychological Testing

DISCLAIMER: Please keep in mind that Mentegram is a healthcare technology company, and do not consider content on our website as legal advice. It is your responsibility to decide to act on this content, relinquishing Mentegram of all claims. The information that we share is based on what has been effective  for our customers and the best practices as published by authoritative sources.
For specifics regarding your individual practice and specific cases, please consult the particular insurance companies or your office’s billing consultant for additional information.