The Ultimate Guide to CPT Codes 99211–99215: Billing E/M Correctly for Established Patients
CPT Code 99211: "The Nurse Visit"
What is it?
CPT 99211 is the only E/M code that does not require a physician’s presence in the room. It is used for minimal services performed by clinical staff (Nurse, MA) under the supervision of a physician.
Typical Time: 5 minutes or less.
Patient Status: Established patients only.
Requirement: The supervising physician must be in the office suite (Direct Supervision) and must have initiated the plan of care during a previous visit.
When to Use It:
A patient comes in for a blood pressure check that was requested by the doctor.
A nurse performs a dressing change or wound check.
Drawing blood (if not billing a separate venipuncture code).
💡 Biller’s Insight: The “Vital Signs” Trap
Do not bill 99211 for trivial tasks. Checking a patient’s weight or temperature alone does not constitute a billable service. There must be a clinical reason (medical necessity) documented.
Wrong: “Patient stopped by to weigh in.”
Right: “Patient presenting for weight check to monitor diuretic therapy effectiveness.”
CPT Code 99212: "The Minor Problem"
What is it?
CPT 99212 represents a visit requiring a Straightforward level of medical decision-making. It is rarely used in modern practice because most clinical encounters meet the criteria for 99213, but it still has a place for self-limited issues.
Typical Time: 10–19 minutes.
MDM Level: Straightforward (Minimal risk, minimal data).
When to Use It:
A quick follow-up for a minor abrasion that is healing well.
A visit where no medication is prescribed, no tests are ordered, and the advice is “rest and fluids.”
💡 Biller’s Insight: Why it gets skipped
Many providers skip 99212 because if they spend 15 minutes talking to the patient about diet or reassurance, they can often bill 99213 based on time. However, if the visit is 10 minutes and clinical judgement is minimal, 99212 is the compliant choice.
CPT Code 99213: The "Standard" Follow-Up
What is it?
CPT 99213 is the industry standard for “Low Complexity” visits. It is the “maintenance” code for stable chronic conditions or minor acute illnesses.
Typical Time: 15–29 minutes.
MDM Level: Low Complexity.
The 2-out-of-3 Rule: To bill 99213 based on MDM, you need 2 of the following:
Problems: 2 minor/self-limited problems OR 1 stable chronic illness.
Data: Limited review of data (Category 1).
Risk: Low risk of morbidity (e.g., OTC meds, physical therapy).
Real-World Scenario:
A patient with controlled hypertension comes in for a refill. BP is 120/80. You continue the current Lisinopril dosage. This is a 99213.
💡 Biller’s Insight: Documenting “Stability”
To secure your 99213 claim, avoid generic notes. Explicitly state: “Hypertension is stable on current therapy.” If you fail to document the status of the condition, an auditor might downgrade this to a 99212.
CPT Code 99214: "The Management Code"
What is it?
CPT 99214 represents Moderate Complexity. This is the target code for internal medicine because it reflects the management of complex or uncontrolled conditions.
Typical Time: 30–39 minutes.
MDM Level: Moderate Complexity.
The 2-out-of-3 Rule: To bill 99214, you need 2 of the following:
Problems: 1 chronic condition with exacerbation OR 2+ stable chronic conditions OR 1 new problem with uncertain prognosis.
Data: Moderate data review (ordering labs, reviewing notes from other doctors).
Risk: Moderate risk (Prescription drug management).
Real-World Scenario:
A patient with asthma comes in reporting night coughing (exacerbation). You listen to lungs, order a spirometry test, and prescribe a steroid inhaler. This is a 99214 because of the prescription management and the worsening condition.
💡 Biller’s Insight: The “Rx” Factor
At Medz Health Services, we remind providers: If you start, renew, or discontinue a prescription drug, you have generally met the “Moderate Risk” criteria. Combined with a chronic condition, you likely have a compliant 99214.
CPT 99214 represents a higher level of care than 99213, involving more complex assessment, planning, and time commitment — but less than 99215, which captures high-complexity encounters.
CPT Code 99215: "The Crisis Code"
What is it?
CPT 99215 is the highest level of care for an office visit. It involves High Complexity decision-making. This code is red-flagged for audits, so use it only when the patient’s life or bodily function is at significant risk.
Typical Time: 40–54 minutes.
MDM Level: High Complexity.
When to Use It:
A patient presents with severe chest pain or neurological symptoms requiring immediate transfer to the ER.
Managing a patient with severe dementia, heart failure, and renal failure, where drug interactions pose a threat to life.
💡 Biller’s Insight: Time is your Friend
Qualifying for 99215 via MDM is difficult (it requires “high risk of morbidity/death”). However, if you spend 40+ minutes with a patient and family discussing care goals, end-of-life planning, or complex coordination, bill by TIME. It is much easier to prove 40 minutes of face-to-face time than “high risk of death” in an office setting.
Summary Comparison Table
| CPT Code | Complexity (MDM) | Typical Time | Best For… |
| 99211 | N/A (Nurse) | < 5 mins | BP checks, suture removal (nurse only). |
| 99212 | Straightforward | 10-19 mins | Very minor issues, minimal doctor work. |
| 99213 | Low | 15-29 mins | Stable chronic conditions, OTC meds. |
| 99214 | Moderate | 30-39 mins | Prescription management, worsening conditions. |
| 99215 | High | 40-54 mins | Severe distress, ER transfer, complex family meetings. |
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