Med check note do's and don'ts for a 99214
A patient who isn't at the treatment goal isn't stable, under the American Medical Association's rules. If you code by medical decision making, "stable" can hold the visit to 99213.
Co-founder, JotPsych
Your 3:00 appointment is a depression follow-up. The Patient Health Questionnaire-9 (PHQ-9) score is 14, the goal is under 5, and you raise the sertraline. Your note says stable out of habit.
Write the symptom score beside the treatment goal
Name the problem's status: not at goal
Add the medication change you made
Calling a patient stable out of habit
Leaving a problem's complexity unwritten
Stopping at a one-line note
Drawn from the American Medical Association's office visit rules and a coding auditor's advice. With all three Do lines, your note shows a moderate problem and moderate risk, which together support a 99214.
Three do's for the note
- Write the symptom score beside the treatment goal. The American Medical Association's office visit rules define stable "by the specific treatment goals for an individual patient." Your patient's PHQ-9 of 14 isn't under the goal of 5. Put both numbers in your note.
- Name the problem's status: not at goal. You can set the level by total time on the date of the visit or by medical decision making. In medical decision making, two of three parts must reach the level: problems, data, and risk. One stable chronic illness counts as a low-level problem. Poorly controlled, the illness counts as moderate.
- Add the medication change you made. Your sertraline increase is prescription drug management, which is moderate risk. With a moderate problem and moderate risk, your note supports a 99214.
Major depressive disorder, stable.
Sertraline increased to 150 mg.
Return in 4 weeks.
Major depressive disorder, not at goal: PHQ-9 of 14, goal under 5.
Poorly controlled; sertraline increased to 150 mg.
Return in 4 weeks.
Prescription drug management is moderate risk in both notes. Only Note B shows a problem that isn't at goal, so only Note B supports a 99214.
Three don'ts for the note
- Don't call a patient stable out of habit. The American Medical Association's rules say "a patient who is not at his or her treatment goal is not stable, even if the condition has not changed." Your patient's score of 14 can hold for months and still sit above the goal.
- Don't leave a problem's complexity unwritten. Name the status of each problem you treat. "Condition complexity is not implied," writes Kem Tolliver, who audits coding for practices.
- Don't stop at a one-line note. Tolliver's example of a weak note was one line: "Follow up encounter, patient is stable." The line names no score, no goal, and no change.
Each year, Medicare checks a sample of claims against the notes behind them. In the 2025 results, established patient visits had 120 errors where the note supported a lower level than billed, and 7 where the note supported a higher level.
Root causes for established patient office visits in Medicare's 2025 improper payment data. Of the notes that supported a different level than billed, nearly all supported a lower level, so check your 99214 notes for a missing status.
Keep "stable" for a patient at goal. Pull five notes you billed as 99214. Check each "stable" against your patient's goal.
Before you sign, JotAudit checks your note against the codes you entered and recommends codes your note supports.
See JotAudit- Kem Tolliver, chief executive officer of Medical Revenue Cycle Specialists, “Strategic Revenue Cycle Workplan Design for High-Impact Payer Engagement,” workshop WS1, Medical Group Management Association (MGMA) 2026 Annual Conference, San Antonio, September 27, 2026.
- American Medical Association, CPT Evaluation and Management (E/M) Services Guidelines, 2023 edition.
- Centers for Medicare & Medicaid Services, 2025 Medicare Fee-for-Service Supplemental Improper Payment Data, November 2025, Table 7: root causes for established patient office visits, claims submitted July 1, 2023, to June 30, 2024.