Established Patient Office Visit (level 5)

This is the top of the five established patient office visit levels — the long, high-complexity appointment. It describes a severe flare of a chronic illness, or a problem that poses a threat to life or to the function of a part of the body, with decisions carrying substantial risk. It is the most expensive office visit code and the one payers scrutinize most.

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What it is

Occasionally an office visit is the moment a serious situation gets sorted out — someone arrives much sicker than expected, or with a result that changes everything, and the decision at the end of the hour is whether to admit them, start a treatment with serious consequences, or escalate care urgently. This level exists for those encounters. High complexity here means an illness in severe exacerbation or progression, or a condition that threatens life or the function of an organ or limb, with extensive information to review and high risk attached to the options. It is the highest-paid of the established patient office visit codes, and precisely for that reason it draws the most attention from payers and auditors.

Why it is done

To manage a chronic illness that has deteriorated badly since the last contact
To assess an acute problem that could threaten life or the function of a body part
To decide on treatment carrying substantial risk, or on hospital admission
To pull together a large amount of information — records, imaging, labs, other clinicians' notes — in a single sitting

What to expect

A visit at this level takes a substantial part of the clinician's day, in the room and around it. Expect extensive discussion, results gathered from several sources, and a plan that may involve urgent testing, a specialist seen quickly, hospital admission, or a treatment with real downsides explained in detail. Some of the clinician's time is spent before and after you are in the room, and that counts toward how the visit is recorded.

Questions worth asking

This is the code most often reduced on review. If my claim is downcoded or denied, does the practice appeal on my behalf, or is the balance passed to me?
If prolonged time beyond this level was spent, is an additional code being billed alongside it?
If the visit ended in hospital admission the same day, does that change how this office visit is billed, and am I charged for both?
Was any of this care delivered by phone or by portal message afterward, and is that billed separately?
Can I get an itemized bill showing every code from this encounter before I pay?

What Established Patient Office Visit (level 5) costs by state

Established Patient Office Visit (level 5) cost in Texas — 86 hospitals, median $367.50
Established Patient Office Visit (level 5) cost in Florida — 74 hospitals, median $770.90
Established Patient Office Visit (level 5) cost in Illinois — 48 hospitals, median $377.40
Established Patient Office Visit (level 5) cost in California — 42 hospitals, median $156.95
Established Patient Office Visit (level 5) cost in Ohio — 37 hospitals, median $168.75
Established Patient Office Visit (level 5) cost in Tennessee — 35 hospitals, median $82.80
Established Patient Office Visit (level 5) cost in Wisconsin — 32 hospitals, median $332.50
Established Patient Office Visit (level 5) cost in Iowa — 31 hospitals, median $265.60
Established Patient Office Visit (level 5) cost in Pennsylvania — 28 hospitals, median $316.00
Established Patient Office Visit (level 5) cost in Georgia — 25 hospitals, median $193.83
Established Patient Office Visit (level 5) cost in Washington — 24 hospitals, median $216.50
Established Patient Office Visit (level 5) cost in New Jersey — 22 hospitals, median $138.18
Established Patient Office Visit (level 5) cost in New York — 22 hospitals, median $487.32
Established Patient Office Visit (level 5) cost in Michigan — 20 hospitals, median $178.74
Established Patient Office Visit (level 5) cost in Virginia — 20 hospitals, median $264.60
Established Patient Office Visit (level 5) cost in Indiana — 19 hospitals, median $522.60
Established Patient Office Visit (level 5) cost in Missouri — 19 hospitals, median $287.10
Established Patient Office Visit (level 5) cost in Arizona — 18 hospitals, median $2,272.34
Established Patient Office Visit (level 5) cost in Minnesota — 17 hospitals, median $232.99
Established Patient Office Visit (level 5) cost in Oklahoma — 17 hospitals, median $264.46
Established Patient Office Visit (level 5) cost in West Virginia — 16 hospitals, median $157.00
Established Patient Office Visit (level 5) cost in Kentucky — 15 hospitals, median $325.80
Established Patient Office Visit (level 5) cost in North Carolina — 14 hospitals, median $374.00
Established Patient Office Visit (level 5) cost in Nebraska — 13 hospitals, median $275.50
Established Patient Office Visit (level 5) cost in Oregon — 12 hospitals, median $411.75
Established Patient Office Visit (level 5) cost in Arkansas — 10 hospitals, median $222.95
Established Patient Office Visit (level 5) cost in Colorado — 10 hospitals, median $588.82
Established Patient Office Visit (level 5) cost in Mississippi — 10 hospitals, median $279.90
Established Patient Office Visit (level 5) cost in South Carolina — 10 hospitals, median $214.50
Established Patient Office Visit (level 5) cost in Kansas — 9 hospitals, median $313.60
Established Patient Office Visit (level 5) cost in Maine — 7 hospitals, median $464.00
Established Patient Office Visit (level 5) cost in South Dakota — 4 hospitals, median $322.40
Established Patient Office Visit (level 5) cost in Wyoming — 4 hospitals, median $1,282.90
Established Patient Office Visit (level 5) cost in Alaska — 3 hospitals, median $497.64
Established Patient Office Visit (level 5) cost in Hawaii — 2 hospitals, median $91.84
Established Patient Office Visit (level 5) cost in Louisiana — 2 hospitals, median $201.24
Established Patient Office Visit (level 5) cost in Montana — 2 hospitals, median $269.60
Established Patient Office Visit (level 5) cost in Nevada — 2 hospitals, median $132.23
Established Patient Office Visit (level 5) cost in North Dakota — 2 hospitals, median $301.60
Established Patient Office Visit (level 5) cost in Maryland — 1 hospitals, median $175.80
Established Patient Office Visit (level 5) cost in New Hampshire — 1 hospitals, median $410.50

Established Patient Office Visit (level 5) prices at hospitals

See every published price for Established Patient Office Visit (level 5): the full national range, the state and hospital breakdowns, and which hospitals charge the least.

Established Patient Office Visit (level 5) cost — see all prices →

Sources

CMS (Centers for Medicare & Medicaid Services): Evaluation & Management Services (opens in a new tab, leaves healthcosts.net)
Medicare.gov: Doctor & other health care provider services (opens in a new tab, leaves healthcosts.net)

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