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Level 4 Established Office Visit (99214)

This code represents the second highest level of care for established office patients. This is the most frequently used code for these encounters. Internists selected this level of ccare for 47.41% of established office patients in 2014. The Medicare allowable reimbursement for this service is $108.13 and it is worth 1.5 work RVUs. Usually the presenting problems are of moderate to high severity. 

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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