CPT 99215: Established Patient Office Visit, High Complexity
CPT 99215 reports an established patient office or outpatient visit with high medical decision making or 40-54 minutes of total time. It is the top established-patient level. In 2026 Medicare pays about $192.39 non-facility (5.76 total RVUs times the $33.4009 conversion factor) and about $125.59 in a facility.
- Code type
- Established patient E/M (office/outpatient)
- 2026 non-facility
- $192.39 (5.76 RVUs)
- 2026 facility
- $125.59 (3.76 RVUs)
- Time (if used)
- 40-54 minutes total on the date
What is CPT 99215 used for?
CPT 99215 is an office or outpatient visit for an established patient requiring high medical decision making or 40-54 minutes of total time. It is the top of the established-patient ladder and should be reserved for genuinely high-acuity encounters: severe exacerbations, threats to life or function, or high-risk management decisions.
You select the level by MDM or by total time under the 2021 E/M rules; history and exam must be medically appropriate but no longer set the code. An established patient is one seen by you or a same-specialty and subspecialty physician in your group within three years. Because 99215 is the highest-paying office visit, it draws payer review, so the note must show the acuity rather than merely a long history.
How much does 99215 pay in 2026?
99215 carries 5.76 non-facility RVUs and 3.76 facility RVUs. At the 2026 conversion factor of $33.4009:
| Setting | Total RVUs | 2026 Medicare allowed |
|---|---|---|
| Non-facility (office) | 5.76 | ~$192.39 |
| Facility | 3.76 | ~$125.59 |
Medicare pays 80 percent of the allowed amount after the deductible; the balance is patient or secondary coinsurance. Confirm your locality-adjusted rate with the Medicare fee calculator.
How do you support and extend a 99215?
Example: an established COPD patient in acute exacerbation, oxygen saturation dropping, you review recent imaging and labs, escalate therapy, and decide whether to hospitalize. That is high problem severity plus extensive data plus high risk, a defensible 99215 (~$192.39). If the encounter runs long, add a prolonged code:
| Add-on | Payer | Trigger |
|---|---|---|
| 99417 | Most commercial | 15 min beyond the minimum (55+ min total) |
| G2212 | Medicare | 15 min beyond the maximum time for 99215 |
Change the facts and the level drops: the same patient in for a stable, unchanged follow-up with no escalation is a 99214 or even 99213, not a 99215. The top level rests on genuine high acuity, severe exacerbation, threat to life or function, or a high-risk management decision, documented in the note.
Frequently asked questions
By time, 99215 requires 40-54 minutes of total time on the date of service. Beyond 54 minutes (or, for Medicare, beyond the maximum), you append a prolonged-services code. If you code by MDM, high complexity controls and time is not required.
The 2026 national non-facility allowed amount is about $192.39 (5.76 total RVUs times $33.4009). In a facility it is about $125.59 (3.76 RVUs). Medicare pays 80 percent after the deductible.
High MDM typically means one or more chronic illnesses with severe exacerbation or progression, an acute illness that threatens life or bodily function, or a decision about hospitalization or de-escalation of care, along with extensive data review or high risk such as drug therapy requiring intensive monitoring for toxicity. Document the severity and the high-risk decision.
Sources & further reading
Reviewed by the ImmediCare Solutions RCM team
Certified billers and coders handling claims across 50+ specialties nationwide. This entry is reviewed against current payer policy and CMS rules. Last review: Jul 5, 2026.
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