Which code is used for a high level re-exam?

• A. 99212
• B. 99213
• C. 99214
• D. 99215

Answer: (D)

A high-level re-exam requires a thorough reassessment of an established patient, combining a comprehensive history, a detailed physical examination, and high-level medical decision making. When a patient returns for follow-up to gauge progress and potentially adjust the treatment plan, the documentation should reflect substantial time and complexity. In outpatient E/M coding, this is represented by the highest level of evaluation and management for established patients, typically indicating extensive time (often around 40–54 minutes) or equivalent breadth of history, exam, and decision making.

The lower levels correspond to progressively simpler encounters: shorter history, fewer systems examined, and less complex decision making. So for a high-level re-exam, the best choice is the code that represents the most comprehensive established-patient office visit, which matches the scenario of an in-depth reassessment and plan adjustment.