CPT® code 99214 is one of the most frequently billed evaluation and management (E/M) codes in physician offices. It represents a moderate‑complexity visit for an established patient, meaning the clinician must address multiple problems or acute conditions and make moderately complex decisions. Selection of this code depends on either the level of medical decision making (MDM) or the total time spent with the patient on the date of the encounter. Because the code is widely used and scrutinized, billing professionals must understand documentation requirements, reimbursement trends and payer‑specific rules to ensure compliance and accurate payment. This article focuses on reimbursement under U.S. government insurance programs—Medicare, Medicaid, TRICARE/CHAMPUS, the Veterans Health Administration (VA) and the Children’s Health Insurance Program (CHIP)—and outlines compliance strategies for 2025.
Defining CPT 99214: MDM and Time Requirements
Moderate‑complexity E/M service
Under 2021‑2024 CPT and CMS guidelines, 99214 may be selected based on either MDM or total time. Medical decision making requires moderate complexity in at least two of three elements: number and complexity of problems addressed, amount and/or complexity of data reviewed and analyzed, and risk of complications or morbidity. The IDSA reference guide lists examples of problems addressed for 99214, including two or more stable chronic illnesses, one undiagnosed new problem with uncertain prognosis, or one acute illness with systemic symptoms. Data complexity may involve reviewing external records, interpreting tests performed by other physicians, or discussing management with another qualified professional. Risk factors commonly cited for 99214 include prescription drug management, decision regarding minor surgery with risk factors or limited by social determinants of healthidsociety.org.
Time‑based coding
Alternatively, 99214 can be billed when the total time spent on the date of service meets the threshold. The IDSA guide’s table of total times shows that the minimal time for 99214 is 30 minutes, and the code covers visits lasting 30‑39 minutes. A clinical example in the same guide illustrates a physician who spent 34 minutes managing a patient with cellulitis; because the time exceeded the 30‑minute threshold, CPT 99214 was appropriate despite a lower MDM level. Total time includes face‑to‑face and non‑face‑to‑face work on the date of the encounter—preparing to see the patient, reviewing records, documenting in the electronic health record, communicating with the patient or family, and ordering medications or tests. However, ancillary staff time (check‑ins, obtaining vital signs) cannot be counted. Documentation should explicitly state the total time (e.g., “Total time: 32 minutes”) and briefly list the activities performed to support time‑based billing.
Importance of accurate documentation
Accurate documentation is critical for 99214 compliance. The 2024 E/M reforms eliminated history and physical exam as drivers of code level; providers must still document an appropriate history and examination, but code selection depends on MDM or timeidsociety.org. Common pitfalls include copying forward previous notes without updating the patient’s current status, insufficient problem documentation, and failing to record prescription drug management detailsbrellium.com. Practices should create visit templates that prompt clinicians to document the status of each problem, data reviewed, risk factors, and total timebrellium.com. Pre‑billing audits and provider training help ensure that documentation supports the level billed and that the distribution of E/M codes aligns with practice benchmarksbrellium.com.
Medicare Reimbursement in 2025
Conversion factor and payment rates
Medicare reimbursement for CPT 99214 is governed by the Medicare Physician Fee Schedule (MPFS), which assigns relative value units (RVUs) for physician work, practice expense and malpractice. These RVUs are adjusted by geographic cost indices (GPCIs) and multiplied by the conversion factor to calculate the national payment ratestreamlinemd.com. For 2025, CMS finalized a conversion factor of $32.3465, a decrease from $33.2875 in 2024 due to budget neutrality adjustments and the expiration of a 2.93 percent temporary increasestreamlinemd.com. VMG Health notes that the 2025 conversion factor represents a 2.83 percent reduction from the previous year and that sequestration continues to reduce payments by 2 percentvmghealth.com.
The American Academy of Sleep Medicine’s 2025 E/M national payment comparison table (from CMS data) shows that the 2024 national payment for 99214 was $126.07, while the 2025 payment will be approximately $125.18, a modest reduction of $0.99aasm.org. The same table lists RVUs of 3.85 in 2024 and 3.87 in 2025, reflecting a small increase to work RVUsaasm.org. With the 2025 conversion factor of $32.3465, the approximate national payment is computed by multiplying the total RVU (3.87) by the conversion factor, yielding about $125.18. Actual reimbursement varies by locality because GPCIs adjust each RVU component.
Other Medicare considerations
Billing professionals should be aware of budget neutrality adjustments and the new add‑on code G2211. The IDSA guide notes that CMS introduced HCPCS code G2211 to recognize visit complexity inherent in primary care and longitudinal management. G2211 may be appended to 99214 when the practitioner serves as the focal point for all needed services or provides ongoing care for a serious or complex condition, but it cannot be billed when modifier 25 is used. Medicare also continues to limit use of CPT codes 99417 and 99418 for prolonged services, substituting G2212 for office/outpatient visits and G0316 for prolonged hospital visitsidsociety.org. Practices should verify that time meets the threshold for these G‑codes before billing.
Medicaid and CHIP: Understanding State Variation
Medicaid reimbursement for CPT 99214 is not standardized; states set their own fee schedules, often as a percentage of Medicare. Historical analyses show that Medicaid fees have long lagged behind Medicare. A 1995 Health Care Financing Review study found that Medicaid physician fees averaged 27 percent lower than Medicare and were 32 percent lower for primary care servicespmc.ncbi.nlm.nih.gov. Although this data is dated, more recent analyses indicate that states have increased Medicaid rates but still fall short of Medicare. An updated Medicaid‑to‑Medicare fee index (2024) reported that physician fees averaged 71 percent of Medicare across 27 services; the ratio was 69 percent for office visits, 68 percent for hospital and emergency department visits, 87 percent for obstetric care, and 79 percent for other services. Between 2019 and 2024, average Medicaid fees increased from 72 percent to 75 percent of Medicare, partly because CMS encouraged states to raise fees to at least 80 percent.
Because states have discretion, payment for CPT 99214 under Medicaid may range from roughly 50 to 90 percent of Medicare. Some states peg their physician fee schedules to a specific percentage of Medicare; for example, a 2025 South Carolina policy (unable to cite due to access limitations) pays certain E/M codes at about 82 percent of Medicare, whereas other states pay closer to parity. Billing professionals must consult each state’s Medicaid provider fee schedule for current rates and be aware of updates enacted by state legislatures. In addition, Medicaid programs may reimburse telehealth visits (including 99214) differently; North Carolina’s telehealth billing guidance confirms that codes 99201–99215 are covered via telehealth and require modifiers such as CR or GT.
CHIP reimbursement
The Children’s Health Insurance Program (CHIP) is funded jointly by federal and state governments using an enhanced Federal Medical Assistance Percentage (FMAP), which averages 71 percent, roughly 15 points higher than Medicaid. States receive annual CHIP allotments and must use the funds to expand coverage for children medicaid.gov. In most states, CHIP fee‑for‑service payments for office visits align with the state’s Medicaid fee schedule, although some states may offer slightly higher rates. Because the program is administered alongside Medicaid, billing professionals should use the state Medicaid fee schedule as a baseline for estimating CHIP reimbursement for 99214 and verify whether separate CHIP schedules exist.
TRICARE/CHAMPUS Reimbursement
CHAMPUS Maximum Allowable Charge (CMAC)
TRICARE, formerly the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), reimburses health‑care professionals using an allowable charge methodology. The eCFR regulations state that TRICARE pays the lower of the billed charge or the local CHAMPUS Maximum Allowable Charge (CMAC). The national CMAC is calculated as the lesser of national prevailing charge levels or national appropriate charge levels and then adjusted for localitiesecfr.gov. Appropriate charge levels are derived by comparing national CMACs with Medicare fees to categorize each procedure as overpriced, underpriced or other; adjustments are made accordingly. Nonparticipating providers cannot balance bill an amount exceeding the Medicare limiting charge percentage; the balance billing limit is the same percentage as Medicare’s. In practice, this means that non‑network providers may not charge TRICARE beneficiaries more than 15 percent above the CMAC, mirroring Medicare’s 115 percent limiting charge.
For TRICARE Prime enrollees, the regulation notes that when care is received from nonparticipating providers, the CHAMPUS reasonable charge is the CMAC plus any balance billing amount up to the limitecfr.gov. The rules ensure that beneficiaries are protected from excessive charges and that provider reimbursement closely parallels Medicare. Billing professionals should consult the regional TRICARE contractor’s fee schedule (often derived from the CHAMPUS Fee Schedule) to determine the allowable charge for 99214 and apply the 15 percent limit for nonparticipating providers.
Telehealth and special circumstances
TRICARE covers certain telehealth services; however, reimbursement may differ from Medicare. Under TRICARE’s authority, the Director may adopt special reimbursement methods for pharmaceutical agents or other services not addressed by Medicareecfr.gov. Providers should verify whether telehealth visits using 99214 require specific modifiers or originate from approved sites.
VA Community Care and Fee Schedule
The Veterans Health Administration (VA) reimburses community care providers through the Community Care Network (CCN). The VA states that it reimburses hospital, medical and extended‑care services up to the maximum allowable rate, which for most services is the Medicare rate. When a Medicare rate does not exist, the VA pays either the VA Fee Schedule rate or a percentage of the billed amount. Therefore, billing professionals should generally expect CPT 99214 to be reimbursed at the Medicare MPFS rate when providing services to veterans in the community. Payments may be subject to sequestration or other federal reductions. As with other programs, accurate documentation and adherence to MDM or time requirements are crucial to avoid payment denials.
Compliance and Audit‑Readiness Strategies
- Document MDM elements clearly. For 99214, ensure that at least two of the three MDM elements meet moderate complexity: multiple problems (e.g., two stable chronic illnesses or one acute illness with systemic symptoms), moderate data review (e.g., ordering tests, interpreting external records) and moderate risk (e.g., prescription drug management)idsociety.org.
- Record total time when using time‑based billing. Include a statement of total minutes and list key activities; do not include ancillary staff workidsociety.org. For 99214, time must be between 30–39 minutesidsociety.org. When time exceeds 40 minutes, consider prolonged services codes (G2212 for Medicare).
- Avoid copy‑pasting notes and ensure individualized documentation. Each visit must reflect the patient’s current condition; copying forward previous notes can trigger auditsbrellium.com.
- Verify payer rules for telehealth. Medicare, Medicaid, TRICARE and VA each have specific requirements for telehealth services, including allowable modalities (synchronous video vs audio‑only) and modifiers. For example, North Carolina Medicaid covers 99214 via telehealth with CR and GT modifiers.
- Monitor coding patterns and conduct pre‑billing audits. Tracking the distribution of 99214 versus lower‑level codes helps identify over‑coding or under‑coding trends. Sampling charts before submission ensures documentation supports the level billed.
- Stay informed about annual fee schedule updates and state‑specific changes. Medicare’s conversion factor and RVUs may change each year; states may revise Medicaid and CHIP rates; and TRICARE adjusts CMACs based on prevailing charges and Medicare fees. Review updates from CMS, state Medicaid agencies, TRICARE contractors and the VA to anticipate revenue impacts.
Conclusion
In 2025, CPT 99214 remains a cornerstone of outpatient billing for established patients with moderate‑complexity problems. Documentation must demonstrate either moderate MDM across at least two categories or total time of 30–39 minutes. Under the Medicare Physician Fee Schedule, the conversion factor drops to about $32.35 and the national payment for 99214 decreases slightly to $125.18, though geographic adjustments will apply. Medicaid and CHIP reimbursements vary widely, averaging around 70 percent of Medicare with significant state‑to‑state variation. TRICARE reimburses using the CMAC, limiting payments and balance billing to levels derived from Medicare feesecfr.gov, while the VA Community Care Program generally pays at Medicare rates. Billing professionals must stay attuned to these differences, verify payer‑specific rules, and maintain meticulous documentation to ensure compliance and optimal reimbursement. By implementing robust audit processes, leveraging technology, and keeping abreast of fee schedule updates, practices can navigate the 2025 reimbursement landscape with confidence.
