Internal Medicine Coding Alert
CPT Defines Level-four and Level-five Office Visits
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The CPT manual requires the following levels of history, examination and medical decision-making for level-four and -five office visits:
Level four:
99204 new patient office or other outpatient visit
a comprehensive history;
a comprehensive examination; and
medical decision-making of moderate complexity
99214 established patient office or other outpatient visit
a detailed history;
a detailed examination; and
medical decision-making of moderate complexity
Level five:
99205 new patient office or other outpatient visit
a comprehensive history;
a comprehensive examination; and
medical decision-making of high complexity
99215 established patient office or other outpatient visit
a comprehensive history;
a comprehensive examination; and
medical decision-making of high complexity.
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