The healthcare system uses Current Procedural Terminology (CPT) Evaluation and Management (E/M) codes to describe and bill for medical services. For established patients—individuals who have received professional services from a provider or their group within the past three years—the relevant codes range from 99212 through 99215. The specific code selected for billing is determined by either the total time spent on the patient’s care or the complexity of the medical decision-making (MDM) involved.
The Specific Time Required for a Level 4 Visit
The CPT code 99214 is designated for a Level 4 office or outpatient visit for an established patient. When using time as the basis for code selection, the provider must meet or exceed a specific duration of total time spent on the date of the patient’s encounter. For the Level 4 code, the required total time is 30 minutes.
Prior to recent revisions, this code was represented by a time range of 30 to 39 minutes. The current guidelines simplify this by stating a minimum threshold, which must be met or exceeded to select the code based on time. This approach ensures consistency in how time-based services are documented across different types of medical encounters.
The calculation of “total time” is not limited to face-to-face interaction with the patient. It encompasses all the work personally performed by the physician or other qualified healthcare professional on the day of the visit. This includes preparing to see the patient, such as reviewing medical records or previous test results, and any time spent obtaining a history that was not separately documented.
Other activities that count toward the total time include counseling and educating the patient or their family, ordering medications, procedures, or tests, and documenting the clinical information in the patient’s medical record. Time spent communicating with other healthcare professionals or independently interpreting tests (when not billed separately) also contributes to the total.
Qualifying Based on Medical Decision Making
If the time threshold is not met or if the provider chooses to use complexity as the determining factor, the Level 4 visit must meet the requirements for Moderate Medical Decision Making (MDM). The overall MDM level is determined by assessing three distinct elements of the clinical encounter. The provider must meet or exceed the requirements for at least two of these three elements to qualify for a Moderate complexity level.
The first element is the number and complexity of problems addressed during the visit. For Moderate MDM, this typically involves a combination of chronic and acute issues, such as two or more stable chronic illnesses, or one chronic illness that is worsening or poorly controlled. It may also involve one undiagnosed new problem with an uncertain prognosis, which requires further investigation.
The second element is the amount and complexity of data to be reviewed and analyzed. To qualify for Moderate complexity, this generally requires the provider to meet a combination of three data points. Examples include reviewing prior external medical records, obtaining a history from an independent source like a family member, and ordering or independently interpreting a diagnostic test.
The third element is the risk of complications and/or morbidity or mortality related to the patient’s management. Moderate complexity is supported by prescription drug management, which involves making decisions about medication dosage, selection, or monitoring. Other examples include the decision to pursue a minor surgical procedure with identified risk factors or an elective major surgical procedure without significant risk factors.
How Level 4 Compares to Other Office Visits
The Level 4 code, 99214, sits between the lower-level and higher-level established patient visits, reflecting a moderate degree of complexity and resource utilization. The Level 3 code, 99213, is one step lower, requiring a minimum of 20 minutes of total time on the date of the encounter.
For a Level 3 visit (99213), the complexity is defined by a Low level of Medical Decision Making. This level applies to encounters involving fewer or less severe problems, such as a single acute, uncomplicated illness or injury, or two stable chronic illnesses. The data review and management risk are also less extensive than what is required for a Level 4 visit.
At the higher end of the spectrum is the Level 5 code, 99215, which signifies the most complex established patient visit. This level requires a minimum of 40 minutes of total time spent by the provider on the date of service. The corresponding complexity is a High level of Medical Decision Making.
A High MDM level for 99215 is reserved for visits addressing severe issues, such as one or more chronic illnesses with severe worsening or a new problem with a high risk of death. The management often involves a decision regarding a major surgical procedure with identified patient risk factors or a decision to escalate care to the hospital setting.