Established Patient Office Visit – High Complexity

CPT Code: 99215

Description: This code is used for the most comprehensive established patient visits—typically lasting about 40 minutes. It requires a comprehensive history, a comprehensive exam, and high complexity MDM.

Key Components:

• History: Comprehensive
• Examination: Comprehensive
• Medical Decision Making: High complexity

This code is reserved for encounters where the patient’s condition is complex and demands extensive evaluation and management.

Documentation Tips:

• Provide in-depth documentation of history and exam findings.
• Clearly justify the high complexity of the medical decision making.
• Include total face-to-face time details if applicable.

Always consult current CPT guidelines and payer policies to ensure documentation supports the selected service level.