99213 vs 99214: what does the note need to show?

A 99214 needs moderate medical decision making (MDM), and a 99213 needs low. The note reaches a level by meeting two of three MDM elements at that level: the problems addressed, the data reviewed or ordered, and the risk of the treatment chosen.

Time is the other route. A 99213 starts at 20 minutes of the clinician's total time on the day of the visit, and a 99214 starts at 30. Here's how to choose between time and MDM. This post covers the MDM route.

What makes a visit low or moderate?

The AMA's MDM table defines each level. Medicare uses the same table for office visits. Here are the two rows that matter for a 99213 or a 99214, in plain words:

MDM element	99213: low	99214: moderate
Problems addressed	One stable chronic illness, one acute uncomplicated illness or injury, one stable acute illness, or two or more minor problems	A chronic illness that's worse, poorly controlled, or causing side effects from treatment; two or more stable chronic illnesses; a new problem with an uncertain outcome; an acute illness with systemic symptoms; or a complicated injury
Data reviewed or ordered	Any two of these: an outside note reviewed, a test result reviewed, a test ordered. Or a history from someone other than the patient	Any three of those items, counting an outside historian as one; or reading a test yourself, like an x-ray image, when you don't bill for the reading; or discussing the patient's care with an outside physician or other professional
Risk of the treatment chosen	Low risk from more testing or treatment	Moderate risk. The AMA's examples include prescription drug management and decisions about minor surgery when the patient has risk factors

A note needs two of the three elements at a level. A visit with moderate problems and moderate risk is a 99214 even when the data is thin.

One definition trips up a lot of notes. The AMA says a patient who isn't at their treatment goal is not stable, "even if the condition has not changed." A patient whose A1c sits above goal has a chronic illness that isn't stable, and that's a moderate problem. The note has to say so, though. A bare lab value with no goal next to it leaves the reader guessing.

What does the same visit look like as a 99213 note and a 99214 note?

A 62-year-old with type 2 diabetes comes in for a three-month follow-up. The A1c ordered at her May visit came back last week at 8.1%, up from 7.2%. She admits she skips her evening metformin because it upsets her stomach. The doctor switches her to the extended-release form, orders a urine albumin test and a repeat A1c for next time, and books a recheck in three months.

That's a 99214's worth of work. Here's how a rushed note records it:

Type 2 diabetes. A1c 8.1. Discussed diet. Metformin. RTC 3 months.

A reviewer reading this sees one chronic illness with no status, a lab value with no context, and a medication name with no decision. It supports a 99213 at best.

And the same visit, written to show what happened:

Type 2 diabetes, worse. A1c 8.1%, up from 7.2% in May; goal under 7%. Skipping evening metformin doses because of stomach upset. Switching metformin 1,000 mg twice daily to metformin ER 2,000 mg once daily with dinner. Ordered urine albumin-creatinine ratio and repeat A1c before next visit. Recheck in 3 months.

Every added line records something the doctor did or decided in the room:

What the second note adds	What it shows in MDM
"Worse," "up from 7.2% in May," "goal under 7%"	The diabetes isn't at goal and is getting worse, so it's a chronic illness with progression. That's a moderate problem.
"Skipping evening metformin doses because of stomach upset"	A side effect of treatment, which also makes the problem moderate.
"Switching metformin 1,000 mg twice daily to metformin ER 2,000 mg once daily"	A prescription decision with the reason behind it. Prescription drug management is a moderate-risk example in the AMA table.
"Ordered urine albumin-creatinine ratio and repeat A1c"	Two unique tests ordered, which count as data at this visit.

Problems and risk now both reach moderate, so the note supports a 99214 without counting the data at all. The second note is about 40 words longer, and it describes the same visit.

The test orders count at this visit because the AMA counts a test in the visit where it was ordered. The A1c the doctor reviewed today was ordered in May, so it already counted at the May visit. More on when test results count as data.

What doesn't change the level?

• Note length. A long history and a full exam don't set the level for an office visit. CMS says history and exam don't select the level of an office visit.
• The size of the problem list. Diagnoses the doctor didn't address today don't count as problems addressed.
• A medication list. A refill or a copied list doesn't show a management decision on its own. See what counts as prescription drug management.
• How hard the visit felt. If the note supports a 99213, bill a 99213.

That last one runs both ways. A note can support a lower level than the one on the superbill, and the right fix is to bill the lower level. Insurance companies now run software that reads your codes and can pay a 99214 as a 99213, so the note has to carry the level on its own. See how payers check E/M codes.

When should you check the level?

Before the note is signed. Once it's signed, adding a missing line takes an addendum, and an addendum written days later is weaker than a sentence written during the visit. A quick read of the assessment and plan with three questions catches most gaps:

1. Does each problem say whether it's at goal, better, or worse?
2. Does each medication line say what was decided and why?
3. Are the tests ordered or reviewed today written down?

This is the AMA's CPT rule, and Medicare follows it for office visits. Most commercial plans do too, but check each plan's policy before you rely on it.

Cortex Lens reads each Practice Fusion note while the chart is still open and shows the visit level its medical decision making supports, 99212 to 99215, up or down. It also shows what would support the next level, so the doctor can write down work that really happened before signing.

Sources: MDM levels, element definitions, and when ordered tests count: AMA, 2023 CPT E/M Descriptors and Guidelines, Table 1 on pages 8–10 and definitions on pages 15–16. Time and MDM for 99214: AMA, CPT code 99214, updated January 26, 2026. Medicare's use of the CPT MDM rules and the role of history and exam: CMS, Evaluation and Management Services, MLN006764, May 2026, pages 23–24.