No, CPT 99214 has no fixed review-of-systems count under 2021 E/M rules; select the code by MDM or total time.
Coders still ask about a set number of review-of-systems items for CPT 99214. That made sense under the old documentation playbook, where a level 4 visit often rode on a “detailed” history. Since 2021, office and other outpatient visits use medical decision making or total time for code selection. A review-of-systems entry still belongs in the chart when medically needed, but there’s no numeric quota tied to the code.
Why The Ros Question Keeps Coming Up
For years, visit levels hinged on three parts: history, exam, and decision making. The history piece packed in chief complaint, history of present illness, review of systems, and past/family/social history. Under that approach, coders tracked how many systems were reviewed to show “problem pertinent,” “extended,” or “complete.” Those habits linger, even though modern office-visit leveling dropped the numeric count.
Legacy Ros Levels At A Glance
Here’s how the classic documentation rules defined review-of-systems depth. This helps you read older notes, audit prior periods, or train teams who still think in those terms.
| ROS Level (Legacy) | Systems Reviewed | What It Means |
|---|---|---|
| Problem Pertinent | 1 | Only the system tied to the current issue is reviewed. |
| Extended | 2–9 | Problem system plus a limited set of other systems. |
| Complete | 10 or more | Problem system plus the rest of the body systems; positives and pertinent negatives listed. |
The counts above come from the federal documentation guide many teams still cite for legacy periods. That same guide allowed the “all other systems negative” note to close out a complete review when the rest were negative.
Review Of Systems Count For CPT 99214: What Matters Now
For office and other outpatient visits, code selection rests on medical decision making or total time on the date of service. The descriptor for 99214 points to a moderate level of decision making or a time range for an established patient. A review-of-systems entry remains part of a medically appropriate history, but the code level does not depend on hitting an extended or complete count.
Two sources frame this shift. The AMA E/M revisions FAQ explains how office visits are leveled by MDM or time. The CMS E/M Services booklet outlines current Medicare teaching and points to how time and MDM drive code selection.
When An Ros Still Adds Value
Many encounters still call for a concise review-of-systems. It supports clinical reasoning, informs risk, and can back up the problem list. Let the patient story guide scope. For a focused rash visit, a short symptom check may be enough. For chest pain or multi-med issues, you may review more systems to reflect clinical reality. Document what you actually assessed, not a prefilled block that adds noise.
Picking 99214 By MDM Or Time
There are two doors to 99214. Use either one; you do not need both.
The Time Route
Code 99214 fits when total physician or qualified professional time on the date of service lands in the 30–39 minute range. Total time can include face-to-face and certain non-face-to-face work on that date, such as chart review, ordering tests, and documentation that anchors the care plan. When time is the driver, record a clear total and list the activities performed.
The MDM Route
Moderate medical decision making requires two of the three elements at a moderate level: problems, data, and risk. The table below compresses the most common triggers. Use it as a quick read when you level an established-patient visit.
| Route | What To Document | Common Triggers For 99214 |
|---|---|---|
| Time | Total of 30–39 minutes on the date of service; include qualifying activities. | Chart review, patient discussion, ordering and interpreting tests, documentation steps. |
| MDM: Problems | Number and complexity of problems addressed at the encounter. | One or more chronic illnesses with a flare; two or more stable chronic illnesses; undiagnosed new problem with uncertain course; acute illness with systemic symptoms. |
| MDM: Data | Amount/complexity of data reviewed and analyzed. | Multiple tests or documents reviewed/ordered; independent interpretation of a test; discussion with an external clinician. |
| MDM: Risk | Risk of complications and/or morbidity from management. | Prescription drug management; decision for minor surgery with patient or procedure risk factors; decision for elective major surgery without risk factors; care limited by social drivers. |
How Ros Interacts With MDM
MDM stands on problems, data, and risk. A review-of-systems entry can support the story but does not score points directly. Use it to:
- Show the scope of symptoms tied to the problems you addressed.
- Record pertinent negatives that affect risk or testing choices.
- Clarify chronic disease control, side effects, or red-flag symptoms.
A long checklist of unrelated negatives adds little value and can distract from the elements that actually set the level.
Fast Rules For 99214 Documentation
Pick Your Door First
Decide up front: time or MDM. If time will carry the day, write a precise total and list what you did. If MDM fits better, show the problems you managed, the data work you performed, and the risk in plain terms.
Write To The Problems You Addressed
State what changed today. For a chronic disease that worsened, say so and describe the new plan. For a new problem with an uncertain course, explain your thinking, tests, and follow-up intent. That narrative supports the problem element in MDM.
Make Data Work Obvious
Name the labs, imaging, outside notes, or tracings you reviewed. If you personally read a test that another clinician billed, say “independent interpretation.” If you called another clinician to talk through the case, note the discussion.
Spell Out Management Risk
State when you start, stop, or change prescription drugs. Note patient or procedure risk factors tied to a planned minor procedure. If social drivers restrict care options, say how that affected testing or treatment.
Ros: Practical Do’s And Don’ts
Do
- Limit the review to systems that matter for the visit.
- Record positives and key negatives that shape risk.
- Use tight phrases that clinicians and coders both understand.
Don’t
- Paste a full systems checklist when only a few items are relevant.
- Rely on “all other systems negative” when you did not ask those questions.
- Chase a number to reach a code; the code does not require it.
Edge Cases And Legacy Charts
Audits on older dates of service can still lean on legacy counts. Under those rules, an extended review meant two to nine systems, and a complete review meant ten or more. If you must abstract a past visit under that scheme, read the note carefully and tally the systems addressed. For current office visits, do not let a numeric target drive your documentation; let the clinical story lead.
Common Myths
“You Always Need Ten Systems For Level 4”
No. That was tied to legacy “complete” review logic. Modern office leveling uses MDM or time.
“Ros Doesn’t Matter Anymore”
It still matters for care. It can also back up risk, such as side effects from therapy or red-flag symptoms in multi-morbid patients. It just doesn’t set the code by itself.
How To Level A Typical Visit
- List the problems you addressed and state their status. Call out worsening, complications, or uncertainty.
- Document the data you ordered, reviewed, interpreted, or discussed with another clinician.
- Record management risk with plain language: drug changes, procedures, or constraints.
- If using time, add a single total in minutes and the work done on the date of service.
- Include a targeted review-of-systems that reflects the symptoms you actually reviewed.
Quick Reference For Teams
Share these cues at huddles and in your EHR templates:
- Time path: 30–39 minutes total for 99214. Record the total and qualifying work.
- MDM path: Moderate level needs two of the three elements at moderate level. Anchor your note to problems, data, and risk.
- ROS: No set count for the code. Keep it focused and clinically driven.
Key Takeaway For 99214 Coding
A numeric review-of-systems count does not set an office level 4 visit. Pick 99214 by moderate decision making or by the 30–39 minute time range. Keep review-of-systems targeted to the encounter. That approach aligns with current AMA guidance on office visits and with Medicare teaching on E/M services.
Current office-visit leveling and the MDM elements are outlined in the AMA’s E/M updates and in Medicare’s E/M booklet. Legacy ROS counts come from the federal documentation guidelines.