Oncology & Hematology Coding Alert

Question: I’m having a hard time understanding the difference between a level 4 and level 5 office visit and what code to use for each. An existing patient with new lymphadenopathy recently came in for a restaging one year after their initial operation. The provider conducted a comprehensive history and a comprehensive exam. Should I code for a level 4 or a level 5 office visit? Which codes are associated with each level?

Arizona Subscriber

Answer: This office visit constitutes a level 5 visit and you should use the code 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity …). You’ll find 99215 in appendix C, and you can also find various clinical examples.

Typically, a level 5 visit includes a comprehensive history, which includes a chief complaint, a complete PFSH, an extended HPI, and ten systems on the ROS guidelines. Also make sure that a comprehensive exam, which performs two types of procedures of at least nine different listed organs for 97 guidelines or an exam of 8+ organ systems or body areas for 95 guidelines, is also included. Level 5 visits also include high complexity medical decision-making, where the provider must review significant patient data in order to determine the best course of action. In this case, the restaging justifies the use of code 99215.

Keep in mind that level 4 visits are not as complex. Though a detailed history needs to be taken, only two to nine systems need to be included from the ROS guidelines and one relevant piece of data needs be reviewed based on the patient’s PFSH. The exams performed at level 4 need to total 12 procedures on any organ system for 97 guidelines or an exam of 2-7 organ systems or body areas with one in greater detail for 95 guidelines. Level 4 office visits involve moderately complex medical decision making, which is when a provider focuses on a single area of a patient’s complaint to determine the best course of action. In cases like these, the code 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity ...) is acceptable.