Office visit for an established patient
CPT® Code 99215 is used to report an office or other outpatient visit for the evaluation and management (E/M) of an established patient. This code is applicable when the total time spent on the date of the encounter is 40 to 54 minutes, or when the medical decision making is of high complexity. This is the highest-level E/M service for established patients.
When to use CPT® Code 99215
This code is appropriate when:
- The patient presents with multiple or serious medical problems.
- The visit involves a high level of complexity in terms of diagnosis, treatment, or risk.
- The provider engages in extensive data review, coordination with other providers, or in-depth patient counseling.
- The provider spends 40–54 minutes total on the date of the visit performing related activities.
The service may be reported based on medical decision making (MDM) or time, depending on which component dominates the encounter.
Medical decision making requirements
To use medical decision making (MDM) as the basis for selecting 99215, the visit must involve high complexity decision making. This includes:
- Number and complexity of problems addressed: One or more chronic illnesses with severe exacerbation, progression, or side effects of treatment; or an acute or chronic illness or injury that poses a threat to life or bodily function.
- Amount and/or complexity of data reviewed and analyzed: Extensive review of external records, tests, or discussions with other health professionals.
- Risk of complications and/or morbidity or mortality: High risk from either the patient’s condition, the diagnostic process, or the treatment options.
Time requirements
When using total time as the deciding factor, you may count all time spent on the date of the encounter, including both face-to-face and non–face-to-face activities such as:
- Reviewing patient history and prior tests
- Performing an examination and evaluation
- Counseling and educating the patient or caregiver
- Ordering tests, medications, or procedures
- Coordinating care with other providers (not separately reported)
- Documenting clinical information in the EHR
- Communicating results and next steps
Important: For CPT 99215, the total time must be 40 to 54 minutes on the date of the encounter.
Key documentation tips
- Specify whether the code is chosen based on MDM or time.
- If time is used, document total time spent and activities performed.
- Ensure the documentation supports the complexity of the visit — especially when using MDM as the basis.
- Include comprehensive history, exam findings, risk factors, and decision-making rationale.
How OptiMantra supports accurate coding for CPT® 99215
OptiMantra, a cloud-based electronic health record (EHR) and practice management platform, simplifies the process of accurately coding and documenting high-level visits like CPT 99215. It supports providers with:
- Time tracking tools that automatically log total encounter duration, including relevant non-face-to-face work
- Smart charting templates designed to guide documentation in line with 99215 requirements
- Built-in coding support, offering suggestions based on inputted history, exam, and MDM
- Audit-friendly logs, ensuring compliance with payer and CMS guidelines
- EHR-to-billing integration for efficient claims generation and faster reimbursements
With OptiMantra, providers can confidently code for complex established patient visits, knowing that documentation, time tracking, and compliance are seamlessly managed in the background.
Try it for free here!
