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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.  Internists selected the 99215 level of care for only about 9% of established office patients in 2014.  The Medicare allowable reimbursement for this level of care is $145.72 and it is worth 2.11 work RVUs. Usually the problems are of moderate to high severity. 

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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