Established Patient Office Visit – Moderate Complexity

CPT Code: 99214

Description: This code is appropriate for established patient visits that typically last about 25 minutes. It requires a detailed history and exam with moderate complexity MDM.

Key Components:

• History: Detailed
• Examination: Detailed
• Medical Decision Making: Moderate complexity

This level of service is used when a more in‐depth evaluation is required.

Documentation Tips:

• Document detailed history and exam findings.
• Include clear notes on the decision-making process.
• Record total time if using time-based criteria.

Verify current documentation requirements to ensure compliance.