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Level 4 Office Visit (99214)

This code represents the second highest level of care for established office patients.  This code ranks 2nd among the most frequently used CPT codes on the planet. Internists use this code for 37.3% of established office patients and should probably use it more often than they do. The reimbursement for this visit is approximately $99, which is pretty good.  Usually the presenting problems are of moderate to high severity. . Most likely, this should be your "routine" level of care. To see why, take the web-course.

The documentation for this encounter requires TWO out of THREE of the following :

1)  Detailed History
2)  Detailed Exam
3)  Moderate Complexity Medical Decision-Making

Or 25 minutes spent face-to-face with the patient if coding based on time.  The appropriate documentation must be included.

Clinical Example

This topic is covered in detail in one of our web-based E/M coding courses.

Established Office Patients

Established Office Visits   Related Topics


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These are the most common patient encounters on the planet, so it's important to code correctly for these visits. Knowing the difference between a level 3 and level 4 established office patient can make a huge difference in your remibursement and income.  
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