InvestigationThe $117 Billion Office Visit Economy
Published February 2026 · 14 min read
Key Finding
Two billing codes — 99214 and 99213 — account for $117.6B in cumulative Medicare payments, more than any other pair of codes in the entire system. Together, they represent 1.8B services — roughly 1.85 billion office visits over 10 years.
The backbone of American medicine isn't surgery or high-tech imaging — it's the office visit. Every year, hundreds of millions of Medicare beneficiaries sit in exam rooms for 10–40 minutes while their doctors assess, diagnose, and manage their conditions. The billing codes for these encounters — the 99211–99215 series for established patients and 99201–99205 for new patients — represent the single largest category of Medicare spending.
And within this category, two codes utterly dominate: 99214 (established patient, moderate complexity, ~25 minutes) at $73.3B, and 99213 (established patient, low complexity, ~15 minutes) at$44.4B.
The Complete Office Visit Landscape
All eight office visit codes combined account for $153.2B — roughly 17.8% of all Medicare spending. This is the foundation of the entire Medicare payment system, and any change to these codes ripples across every medical practice in the country.
The Upcoding Concern: 99214 vs. 99213
One of the most closely watched metrics in Medicare oversight is the ratio of 99214 to 99213 billing. The 99214 code pays about $72.68 per visit — 47% more than the $49.50 for a 99213. The key difference is supposed to be medical complexity and time spent.
The concern: 99214 is now billed 1.12x more often than 99213. With 974.7M services coded as 99214 versus 870.5M as 99213, the higher-paying code has overtaken the lower one in volume.
⚠️ The Upcoding Red Flag
Our upcoding analysis confirms: the national 99214-to-99213 ratio is 1.44, with 53.2% of all E/M visits now coded as 99214. Over the past decade, the 99214 share rose from 41.5% to 52.8%. If just 10% of 99214 visits were actually 99213-level encounters that were "upcoded," the cost to Medicare would be approximately $2.3B in overpayments over the analysis period.
Explore the full upcoding analysis →
Not all 99214 billing represents upcoding. The 2021 E/M documentation changes actually shifted coding guidelines to focus on medical decision-making rather than documentation length, which legitimately increased 99214 usage. But the trend predates 2021, and the OIG has flagged office visit upcoding as a persistent concern.
What These Visits Actually Look Like
Understanding what each code represents helps illuminate the stakes:
99212 — Straightforward
Simple follow-up: checking a healing wound, stable chronic condition. ~10 min.
$30.66
99213 — Low Complexity
Routine chronic disease management: adjusting blood pressure med, diabetes check. ~15 min.
$49.50
99214 — Moderate Complexity
Multiple conditions, new symptoms, or drug interactions. Requires more clinical judgment. ~25 min.
$72.68
99215 — High Complexity
Complex multimorbidity, severe symptoms, difficult diagnostic or therapeutic decisions. ~40 min.
$104.43
The Taxpayer Cost
To put the $117.6B in perspective:
- It exceeds the entire GDP of Ecuador ($110 billion).
- It's more than the combined annual revenue of Pfizer and Merck.
- It could fund NASA's budget for 4.7 years.
- It represents about $11.7 billion per year — or $182 per Medicare beneficiary annually just for these two codes.
The Office Visit Economy
$117.6B
99213 + 99214 combined
17.8%
Share of all Medicare
1.12x
99214 to 99213 ratio
Who Bills These Codes?
Nearly every physician specialty bills office visit codes, but the concentration is highest in primary care. Internal Medicine ($77.0B total payments) and Family Practice ($44.3B total) are the two largest specialties by Medicare payments, and office visits constitute the majority of their billing.
The 99214 code alone has 4.2M unique billing providers — meaning more than a third of all Medicare providers bill this single code. It's arguably the most universal billing code in medicine.
Why This Matters
Office visits are the gateway to everything else in medicine — every referral, every prescription, every surgery begins with an office encounter. The $117.6 billion spent on just two codes reflects the volume-driven nature of American healthcare, where doctors must see many patients to earn sustainable income.
The ongoing shift toward 99214 coding raises important questions: Are patients genuinely sicker and more complex? Are documentation requirements driving legitimate coding changes? Or is there systematic upcoding that costs taxpayers billions? The answer is likely all three, in varying proportions — and getting the mix right is essential to maintaining Medicare's financial sustainability.
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