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Level 5 Office Visit (99215)

The 99215 represents the highest level of care for established patients being seen in the office.  Rather surprisingly, this is the second least popular code used to bill for these encounters.  Internists select the 99215 level of care for only 5% of established office patients.  The reimbursement for this level of care is approximately $133, which is not bad.  Usually the problems are of moderate to high severity.  You are almost certainly under-utilizing this level of care (take the web-course to see why).

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

1)  Comprehensive History
2)  Comprehensive Exam
3)  High Complexity Medical Decision-Making

Or 40 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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