The Short Answer
Bill 99215 when the visit needed high medical decision making, or at least 40 minutes of the provider's total time that day. Bill 99214 for moderate decision making, or at least 30 minutes. You can pick the level by decision making or by time, whichever supports the higher level.
Both codes are for established patients in an office or other outpatient setting. If you are not sure the patient is established, use our new vs established patient checker.
99214 vs 99215 at a Glance
| 99214 | 99215 | |
|---|---|---|
| Medical decision making | Moderate | High |
| Total time on the day of the visit | 30 minutes or more | 40 minutes or more |
| Work RVUs (2026) | 1.92 | 2.80 |
| Total RVUs, office (2026) | 4.06 | 5.76 |
| Medicare 2026, office (national) | $135.61 | $192.39 |
| Medicare 2026, facility (national) | $84.50 | $125.59 |
Rates come from the CMS 2026 fee schedule at the $33.4009 conversion factor, before your local adjustment. Check your area in our Medicare fee lookup.
Choosing by Time
Total time means everything the provider did for that patient on the day of the visit. That includes reviewing records and tests, talking with the patient, ordering, writing the note and coordinating care. It does not include time spent by staff.
| Code | Total time needed |
|---|---|
| 99213 | 20 minutes or more |
| 99214 | 30 minutes or more |
| 99215 | 40 minutes or more |
| 99215 + one prolonged unit | Medicare (G2212): 69 minutes. Most other payers (99417): 55 minutes |
Medicare counts prolonged time differently from CPT, so the same visit can earn a prolonged unit from one payer and not another. Our prolonged services calculator works out the code and units for you.
Choosing by Medical Decision Making
Medical decision making has three parts. A visit reaches a level when two of the three parts meet it.
| Part | Moderate (99214) | High (99215) |
|---|---|---|
| Problems | A long-term illness that is getting worse, two or more stable long-term illnesses, or a new problem with an unclear outcome | A long-term illness with a severe flare or serious progression, or an illness or injury that threatens life or a body function |
| Data | One of three: three items such as tests, outside notes or an independent historian; reading another provider's test yourself; or discussing the case with an outside provider | Two of those three categories |
| Risk of the plan | Moderate, such as managing a prescription drug | High, such as deciding on hospital admission, a drug that needs intensive monitoring for toxicity, or a decision about major surgery |
Three Examples
99214: A patient with stable diabetes and high blood pressure has a blood pressure drug changed. Two stable long-term illnesses make the problems moderate, and the prescription change makes the risk moderate. That is 99214.
99215: A patient with COPD comes in with a severe flare. The provider reviews outside records and new test results, then decides whether to admit the patient to the hospital. The severe flare makes the problems high, and the admission decision makes the risk high. That is 99215.
99215 by time: The provider spends 45 minutes in total that day reviewing a complex medication list, talking with the patient and calling the patient's cardiologist. Time alone supports 99215.
What Picking the Wrong Level Costs
The 2026 Medicare difference is $56.78 a visit in an office ($192.39 minus $135.61), and $41.09 in a facility setting. A provider who codes five 99215 visits a week as 99214 gives up about $14,200 a year at Medicare rates.
Overcoding costs more in the end. 99215 is the visit level payers review most. They compare each provider's mix of levels with their peers, and a high share of 99215 without strong notes can lead to records requests and paybacks. Check a visit against the rules with the E/M code level calculator before you bill it.
Add-On Codes Worth Knowing
G2211 adds $17.37 nationally to a Medicare office visit when the provider is the patient's ongoing point of care for a serious or complex condition. Modifier 25 goes on the visit when a separate, significant E/M happens on the same day as a minor procedure. See our modifier 25 guide.
Related
Read 99213 vs 99214, the full CPT 99214 guide, and RVU values for common CPT codes.
Frequently Asked Questions
Reviewed by Hassan Raza Awan, Founder — 4+ years of hands-on U.S. medical billing experience. General billing information — verify against current CMS guidance and your payer contracts.
Rates drop about 3% in 2027, and G2211 becomes modifier B1. See our 2027 fee schedule guide. See what your visit mix adds up to with our wRVU calculator.
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