Medicare Fee for Office Visit CPT Codes – CPT Code 99213, 99214, 99203

 Here is the Fee schedule or allowed amount from Medicare for the CPTs if it has been performed in office setup . POS 11. This amount will vary from state to state and this amount is for Florida state.

CPT CODE         2016 Fee   2017 FEE

99201 $35.96     $43.6
99202 $61.32     $74.5
99203 $89.52    $108.3
99204 $135.38  $165.7
99205 $169.54  $208.2
99211 $20.07    $19.63
99212 $37.17     $43.1
99213 $58.89     $72.7
99214 $88.33     $107.2
99215 $118.95    $144.8

90658 $13.22  
G0008 $18.57
90732 $29.73
G0009 $18.57
90703 $20.21
90471 $20.87
90472 $10.13
90746 $57.26
J3420 $0.55
J0780 $1.11
J1940 $0.25
94760 $2.64
94010 $34.75
81002 $3.57
81000 $4.43
86580 $8.66
82947 $5.48
82270 $4.54
86510 $9.46
93000 $23.11       $18
69210 $44.76       $51
46600 $77.55
36415 $3.00
90632 $53.45

Medicaid – Update of the Practitioner Fee Schedule Effective 7/1/2016

The Florida Legislature appropriated additional funding during the 2016 Legislative Session to the Agency for Health Care Administration (Agency), to provide a rate increase for certain critical neonatal intensive care and pediatric intensive care unit services covered under Florida Medicaid.

The Agency is increasing the reimbursement for the following critical care Current Procedural Terminology (CPT) codes for services provided through the fee-for-service delivery system.  This change is retroactively effective to July 1, 2016.

Updates to Practitioner Fee Schedule

Effective July 1, 2016

Procedure Mod FSI PCI TCI PA AS
99468 577.84
99469 243.46
99471 537.26
99472 250.83
99475 353.26
99476 212.22
99477 218.73
99478 83.76
99479 76.16
99480 73.13
The Agency will reprocess claims submitted directly to the Medicaid fiscal agent (fee-for-service claims) for dates of service beginning July 1, 2016 to make adjustments to the amount paid to providers to align reimbursement for these CPT codes with this change.  However, it may take several months for the reprocessing task to be completed.  Providers have the option of voiding and resubmitting previously paid claims in order to effectuate quicker reimbursement.

Providers should refer to their contract with each health plan to determine whether this change will impact their reimbursement from the plan for services provided to managed care enrollees


Medicare Part B pays for physician services based on the Medicare PFS, which lists the  more than 7,000 unique codes and their payment rates. Physicians’ services include:

* Office visits
* Surgical procedures
* Anesthesia services
* A range of other diagnostic and therapeutic services Physicians’ services are furnished in all settings, including:
* Physicians’ offices
* Hospitals
* Ambulatory Surgical Centers
* Skilled Nursing Facilities and other post-acute care settings
* Hospices
* Outpatient dialysis facilities
* Clinical laboratories
* Beneficiaries’ homes


The Medicare PFS payment rates formula shows how a payment rate for an individual service is determined, and we provide a description for each component below the formula.

1) Relative Value Units (RVUs) Three separate RVUs are associated with calculating a payment under the Medicare PFS:

* The Work RVU reflects the relative time and intensity associated with furnishing a Medicare PFS service

* The Practice Expense (PE) RVU reflects the costs of maintaining a practice (such as renting office space, buying supplies and equipment, and staff costs)

* The Malpractice (MP) RVU reflects the costs of malpractice insurance

2) Geographic Practice Cost Indices (GPCIs) Each of the three RVUs are adjusted to account for geographic variations in the costs of practicing medicine in different areas within the country. These adjustments are called GPCIs, and each kind of RVU component has a corresponding GPCI adjustment.

3) Conversion Factor (CF)

To determine the payment rate for a particular service, the sum of the geographically adjusted RVUs is multiplied by a CF in dollars. The statute specifies the formula by which the CF is updated on an annual basis.

CPT Code 99214,99213 E&M Coding Established Office Patient Correctly for Medicare Reimbursement

Learn how to correctly bill CPT Code 99214 instead CPT 99213 or CPT 99212 Codes for Evaluation and Management (E&M) Coding of Established Office Patient to increase revenue through legitimate Medicare reimbursement.

CPT Code 99214, if billed correctly, can increase revenue for the practice. By only using CPT code 99212 and CPT Code 99213 many providers are losing thousands of dollars in legitimate revenue yearly. It can be avoided with the correct billing of the 99214 E/M Code.

The CPT definition of a new patient underwent subtle changes in 2012. Unfortunately, CMS did not change their definition to stay aligned with these changes. This difference in language has caused great confusion for many qualified healthcare practitioners trying to stay compliant with the complex rules and regulations of E&M.

Current 99214 CPT Code Description includes the comment note “Typically, 25 minutes are spent face-to-face with the patient and/or family.”. So as per description notes the provider spends approximately 25 minutes face-to-face with the patient for billing CPT 99214.

It is important while selecting time-based CPT codes, that the provider must have spent a time closest to the code selected. For example, 99214 CPT code has a time of 25 minutes, and 99213 has a time of 15 minutes. If the Provider-Patient face-to-face encounter is 21 minutes, select code 99214 since the time spent is closer to 99214 than 99213 as specified in CPT description.

CPT Code 99214 is assigned to the medical service that complies with the following requirements:
The patient is an established one, meaning is not their first visit.

It must be an outpatient visit, meaning it must not incorporate a day of hospital time.
It must meet or exceed to of the following three points:
A detailed medical history
A detailed medical exam
A medical decision that entails moderate complexity.
The severity of the problem that brings the patient to the clinic must be from a moderate to a high one. 5. And last, the doctor and the patient should have a maximum of 25 minutes face time.
CPT Code 99214 Increases Medicare Revenue
Medicare and other Insurance are pleased to pay the lesser money to providers if they (the doctors) are willing to under use the CPT code 99214. The key to using this code correctly is to understand the proper use and the components required to fully capture the most out of all of your encounters. As a provider, you will be rewarded the fruits of your labor when you take the time to learn the components of this code and use it properly.

When you consider CPT code 99214 it has a higher return rate linked to it, however, it must fall under the purview of a moderate complexity to a high severity problem. The physician, if using time as a factor must have spent at least 25 minutes in a face to face scenario with the patient. However, the time component is only a guide and not completely required if the components are included in the visit and the required medical necessity is present. The physician must be able to furnish the two or three areas which include history, physical exam and medical decision making with the proper documentation when filing for the CPT code 99214.

The patient encounter, composed of a detailed history, detailed patient exam and moderate complexity in the medical decision making will justify the use of CPT 99214 as long as the medical necessity is apparent.

For example, you have an established office patient with hypertension, diabetes and a history of dyslipidemia who you are seeing on follow-up in the office. Under the 1997 guidelines you can use three chronic and stable conditions to qualify for the higher code within the history component.

Document the medications and the review of systems along with the proper past medical, family and social history and the first component is met. Document the proper physical exam using appropriate organ system approach six areas with two bullets each and you have met the requirement for the complexity in this area.

At this point, technically you have reached the level 4 criteria since there only needs to be two out of three components required for an established patient.

However, we feel that it is difficult to not have a medical decision-making component so we include that in our progress note. You can document the lab results for the patient and further solidify the visit to qualify for the higher code. As long as the medical necessity is present to justify the work done during the visit the coding can be at the higher level.

99214 vs 99213 CPT Codes Billing

In above Example, most providers will code the example as a CPT 99213, however, the qualifiers are present for the higher CPT 99214 code.

While evaluating three different medical problems such as Hypertension, Diabetes, and Hyperlipidemia, using the 1997 rules, you have met the medical necessity component as well, due to the need to monitor these diseases and help the patient with his/her control.

However, meeting the proper criteria required to code the encounter will enable a medical biller to get the rewards for his career and his practice. It also becomes important, because nowadays Medical Billing and Coding Business are facing potential cuts in the reimbursements for the services the bill.