The short version
- 99214 is a level 4 office visit for an established patient. Moderate-complexity medical decision making, or 30 to 39 minutes of total time on the date of service. Either path on its own.
- Moderate MDM means two of three grid elements reach moderate: problems addressed, data reviewed, or risk. Not all three.
- Two or more stable chronic illnesses puts the problems column at moderate. Prescription drug management puts the risk column at moderate. Together, that is a 99214 with nothing else needed.
- 2026 Medicare pays about $136 nationally for 99214, non-facility, against a conversion factor of $33.40 for non-QP clinicians and $33.57 for QPs.
- Office visits were exempt from the 2026 efficiency adjustment that cut work RVUs 2.5% across roughly 7,700 codes.
What 99214 actually requires in 2026
History and exam no longer set the level. You document them as medically appropriate and they carry no scoring weight. What determines the level is medical decision making or total time.
By MDM, 99214 is moderate complexity, which is a defined bar with a defined grid. The next section walks it.
By time, 99214 is 30 to 39 minutes of total time on the date of service. That counts chart review before the visit, the visit itself, and the note, as long as it all happens that day. It does not count staff time, and it does not count work you finish the next morning.
Under 30 minutes on the time path and it is a 99213. At 40 minutes it is a 99215 on time alone.
Moderate MDM on an established patient
The grid has three columns and you need two of them at moderate. Not all three. That single fact is worth more than any other line in this article.
Problems addressed. Moderate means one chronic illness with exacerbation, progression, or treatment side effects; or two or more stable chronic illnesses; or one undiagnosed new problem with an uncertain prognosis; or one acute illness with systemic symptoms; or one acute complicated injury.
Data reviewed. Moderate means any one of: a combination of three items across external notes reviewed, unique tests ordered or reviewed, and an independent historian; or an independent interpretation of a test someone else performed and billed; or a discussion of management with an external physician or qualified professional.
Risk. Moderate means prescription drug management; or a decision about minor surgery with identified patient or procedure risk factors; or a decision about elective major surgery with no identified risk factors; or a diagnosis or treatment significantly limited by social determinants of health.
In a specialty office, most legitimate 99214s land on the same two columns. Two stable chronic conditions is the problems column at moderate. Writing, renewing, or adjusting a prescription is the risk column at moderate. That is two of three, and the visit is a 99214 before you have counted a single lab.
What 99214 pays in 2026
Medicare’s 2026 conversion factor is $33.40 for clinicians who are not qualifying APM participants and $33.57 for those who are, both effective January 1, 2026. At 4.06 non-facility RVUs, 99214 lands at about $136 nationally before locality adjustment. The same code in a facility setting pays about $85, which is a practice-expense difference rather than a coding one.
Two things beyond the rate. The 2026 efficiency adjustment cut work RVUs by 2.5% across roughly 7,700 codes and did not touch office visits — CMS exempted the time-based E/M family, 99202 through 99215. Separately, indirect practice expense for facility-setting work was cut in half, which shifts money toward care delivered in your own office. If your visits happen under your own roof, 2026 is a better year than 2025 for this code family.
| Code | Level | Time (total, date of service) | MDM | 2026 national average |
|---|---|---|---|---|
| 99211 | 1 | n/a | n/a | ~$24 |
| 99212 | 2 | 10-19 min | Straightforward | ~$59 |
| 99213 | 3 | 20-29 min | Low | ~$95 |
| 99214 | 4 | 30-39 min | Moderate | ~$136 |
| 99215 | 5 | 40-54 min | High | ~$192 |
What a 99214 note has to show
Practices downcode to 99213 because 99214 feels like it invites attention. The level is not what invites attention. A level that the note cannot explain is.
Three things make a 99214 defensible, and none of them add time to your day:
Name the problems and their status. “Psoriasis, stable on current therapy. Atopic dermatitis, stable.” Two stable chronic illnesses, stated as such, is the problems column at moderate. A note that says “doing well” is not.
Say what you did about the medication. Started, stopped, adjusted, renewed, or continued with a specific reason. That is prescription drug management, and it is the risk column. “Continue current meds” with no reasoning reads as nothing happening.
Attribute what you reviewed. If you read the referring physician’s notes or an outside path report, say so and say where it came from. External source attribution is what turns reading into the data column.
An auditor is not looking for a longer note. They are looking for a note where the level and the record agree. Three sentences usually does it.
Five mistakes that turn a clean 99214 into a denial
- Requiring all three MDM columns at moderate. You need two.
- Using “30 or more minutes.” The range is 30 to 39. At 40 it is a 99215.
- Billing 99214 for a routine post-op visit inside a 10 or 90 day global period. That visit is included in the surgical fee — our global period lookup has the day counts.
- Missing modifier 25 when a biopsy or destruction happened at the same visit.
- Downcoding to 99213 by reflex when the note already supports moderate.
Frequently asked questions
What is CPT code 99214?
A level 4 office or outpatient visit for an established patient, supported by either moderate-complexity medical decision making or 30 to 39 minutes of total time on the date of service. Either path qualifies on its own.
How much does 99214 pay in 2026?
About $136 nationally under Medicare, non-facility, before locality adjustment. The 2026 conversion factor is $33.40 for clinicians who are not qualifying APM participants and $33.57 for those who are, both effective January 1, 2026.
What is the difference between 99213 and 99214?
MDM complexity and time. 99213 is low-complexity MDM or 20 to 29 minutes; 99214 is moderate-complexity MDM or 30 to 39 minutes. Either path gets you there on its own. The payment difference is about $40 per visit.
What counts as moderate medical decision making?
Two of three grid elements at moderate. Problems addressed: one chronic illness with exacerbation, two or more stable chronic illnesses, one undiagnosed new problem with uncertain prognosis, or an acute illness with systemic symptoms. Data: three combined items, an independent test interpretation, or discussion with an external clinician. Risk: prescription drug management, or a decision about minor or elective major surgery.
Does refilling a prescription support a 99214?
Prescription drug management puts the risk column at moderate, including renewing or adjusting an existing medication when the note shows the reasoning. You still need a second column at moderate, most often two or more stable chronic illnesses, because moderate MDM requires two of three.
How long does a 99214 visit have to be?
It does not have to be any particular length if you are coding on medical decision making. If you are coding on time, the range is 30 to 39 minutes of total time on the date of service, including same-day chart review and documentation.
Can 99214 be billed with a procedure on the same day?
Yes, with modifier 25 appended to the E/M, and only when the evaluation was significant and separately identifiable from the procedure. Missing modifier 25 is one of the most common dermatology denials.
Is 99214 affected by the 2026 efficiency adjustment?
No. CMS exempted time-based services, including the E/M office visit family 99202 through 99215, from the 2.5% efficiency adjustment applied to roughly 7,700 other codes in 2026.
This article explains how these codes tend to get paid — it is not coding, billing, or legal advice. Some of the codes here are bundled into the main procedure, or fall into grey areas that vary by payer. Before billing anything in a grey area, confirm it with your own coding and compliance team and the current guidance from the American Academy of Dermatology (AAD), Medicare (CMS), and AMA CPT. When in doubt, don’t bill it.
