Nephrology, coded right.

99214 is the workhorse of primary care and most outpatient subspecialties. Use it when at least one of these is true: two or more chronic problems with progression, treatment changes, or side effects; one undiagnosed new problem with uncertain prognosis; one acute illness with systemic symptoms; or prescription drug management at any complexity. Prescription drug management on its own satisfies the moderate-risk element, which is why straightforward chronic disease follow-ups with a med adjustment routinely clear the 99214 bar. Time-based alternative is 30 to 39 minutes of total time on the date of the encounter. Pick the method that supports the strongest note: encounters with prescription changes are usually cleaner under MDM; encounters with extensive counseling or care coordination are usually cleaner under time.

Use 99215 when the encounter genuinely required high-complexity decision-making: severe exacerbation or decompensation of a chronic illness, an acute or chronic illness or injury that poses a threat to life or bodily function, decision regarding hospitalization, drug therapy requiring intensive monitoring for toxicity, or extensive comorbidity management driving a high-risk decision. Real examples: a CHF patient with new bilateral leg edema and dyspnea where you considered emergency admission; a new-onset AFib with RVR you elected to manage outpatient with same-day rate-control titration; an oncology patient with febrile neutropenia. Time-based alternative is 40 to 54 minutes of total time on the date of the encounter.

Pediatric ESRD <2 years, 4+ face-to-face dialysis visits in the calendar month.

Pediatric ESRD ages 2-11, 4+ face-to-face dialysis visits in the calendar month.

Adolescent ESRD ages 12-19, 4+ face-to-face dialysis visits in the calendar month.

Adult ESRD patient on chronic dialysis, 4+ face-to-face visits in the calendar month.

Adult ESRD with 2-3 face-to-face dialysis visits in the calendar month.

Adult ESRD with exactly 1 face-to-face dialysis visit in the calendar month.

Home dialysis monthly cap for pediatric patients under 2 years.

Per-diem ESRD billing when patient is not on chronic dialysis for the full month (e.g. transplant, hospitalization, death).