billing cpt 99215

Procedure 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. Counseling and/or coordination of care with other physicians, other healthcare professionals or agencies are provided consistent with the nature of the problem(s) and the patients and/or family needs, usually the presenting problem(s) are of moderate to high severity, typically 40 minutes are spent face to face with the patient and/or family present to you that we should be coding more 99215 unlike the 99205, which are reserved for train wrecks dying in your office.

What does a 99215 require. I think we have been through what the majority of E and M codes look for. 3 parts History, Examination AND Medical Decision Making. In this case it requires

1. Comprehensive History
2. Comprehensive Examination
3. Medical Decision Making of High Complexity

Most people look at that and say, wow "High Complexity" I'm not so sure my patient with 5 diseases which I control rather well is complex........I say, "Give yourself some credit!"

Most importantly, with your established patient visits, you only need 2 out of 3 to make the grade for 99215 .......

Let's look at what a 99215 looks like clinically.

CHF exacerbation in a 60 year old man with diabetes and CHF with an EF of 35%. He notes increased SOB/DOE and leg swelling.


How about a 58 year old male with COPD and DM2 who presents with change in cough and increased medication utilization. He also notes a new fever.

As you can see, these are not TOO COMPLICATED as in not like an ICU patient on a ventilator, but these are sick patients......

99215 is for your sick but not dying patients......The ones you might end up admitting to the hospital, but often show up in the office on Friday afternoon.

Let's look at the cases and the requirements.

1. Comprehensive History.
There are 4 levels of History. Usually we end up doing detailed or comprehensive. This requires

A. 4 elements from History of Present Illness (think PQRI) Or 3 chronic stable problems!

B. 10 point ROS, a given with “All other systems reviewed and are negative.”
C. Plus a complete Past Family/Medical/Social History, which if there is no change you can document "No change since last reviewed fully on Date X". On your initial you need

That is It. That is all that you need for a Comprehensive history...

Oh, the elements for HPI. Didn't I go over those before? Fine! FYE (Edification)
    1. Location
    2. Quality
    3. Severity
    4. Duration
    5. Timing
    6. Context
    7. Modifying Factors
    8. Associated Signs and Symptoms
And the PFSH? Remember, it only takes ONE element from EACH component of PFSH to qualify for a complete PFSH. Do what is clinically needed. This is an easy one to get.

Next up.
2. Complete Physical Examination.
This requires: 2 bullets from Nine of the 14 organ systems. You get one point for VS and One point for General Exam-This is called the constitutional system.......

You then need 2 items in 8 other systems. Here are the systems.
The 1997 E/M guidelines recognize the following organ systems:
  • Constitutional
  • Eyes
  • Ears, nose, mouth and throat
  • Neck
  • Respiratory
  • Cardiovascular
  • Chest (breasts)
  • Gastrointestinal (abdomen)
  • Genitourinary (male)
  • Genitourinary (female)
  • Lymphatic
  • Musculoskeletal
  • Skin
  • Neurologic
  • Psychiatric
14 Systems. You can't count Male and Female genitalia on MOST patients......

So if you do just these 2, then you qualify for a 99215. I should stop here.....
But I won't. The last of the 3 categories is the Medical Decision Making.

3. Medical decision making
Also judged by 3 categories. You only need 2 of the 3 at the highest level to meet the standards......

Those 3 categories are

Problem Points-4 points are Needed
Data Points-4 points are Needed
Medical Risk-High Risk is Needed

Remember, you only need 2 of 3 here.

How does it tally?

Problem Points
  • New Problem with work up-4 points
  • New Problem with NO work up-3 points
  • Established Problem, worsening-2 points
  • Established Problem, Stable-1 point
Data Points
  • Independent Review of EKG/Film/Specimen-2 Points
  • Review of Old Records-2 Points
  • Labs/EKG/Film/PFTs Ordered/Reviewed-1 Point
  • Discussion with Physician regarding test-1 Point
Medical Risk

Check the table or Just hit one of these
  • One or more chronic illness, with severe exacerbation or progression
  • Acute or chronic illness or injury, which poses a threat to life or bodily function (Tough)
  • Cardiovascular imaging, EGD, or EP studies?
  • Elective Major Surgery or Emergent Major Surgery
  • Drug therapy requiring intensive monitoring for toxicity i.e. Heparin
  • Decision to make DNR
Remember you only need 2 of the 3 here too.....Which means you likely will hit Data Points and Problem points more often than Risk points.....

So what I am saying is, if you have a patient with 3 chronic problems or if you have a patient with some new problems which make the patient sick, then you likely have a 99215. Internists used the 99215 to bill for only 4.1% of established office patients in 2003. Which IMHO is too low.

CPT code is 99215, the Comprehensive assessment. This code requires at least two out of these three components

o A comprehensive history
o A detailed examination
o Medical decision making of high complexity

When billing code 99215, a good tip is to note that this assessment is broad in scope or content demonstrating extensive understanding of the patient’s condition. Most likely, the presenting problems are of moderate to high severity. Typically 40 minutes are spent face-to-face with the patient and/or family.

Billing Preventive Medicine Evaluation & Management (E&M) Services

* Preventive Medicine E&M services should be reported using the age appropriate code from the Preventive Medicine Services section of the most current CPT manual.

* Services rendered should be reported using 99381-99387 for new patients or 99391-99397 for established patients. These codes include counseling/anticipatory guidance/risk factor reduction interventions which are provided at the time of the  initial or periodic comprehensive preventive medicine examination.

* If an abnormality/ies is encountered, or a preexisting problem is addressed in the process of performing a preventive medicine E&M service, and if the problem/abnormality is significant enough to require additional work to perform the key components of a  problem-oriented E&M service, then the appropriate Office/Outpatient code 99201-99215 should also be reported.

Modifier-25 should be added to the Office/Outpatient code to indicate that a significant; separately identifiable E&M service was provided by the same physician on the same day as the preventive medicine service.

Note: An insignificant or trivial problem or abnormality that is encountered in the process of performing the preventive medicine E&M service and which does not require additional work and the performance of the key components of a problem-oriented E&M service should not be reported

Payment for Office or Other Outpatient Evaluation and Management (E/M) Visits (Codes 99201 - 99215) 

A. Definition of New Patient for Selection of E/M Visit Code Interpret the phrase “new patient” to mean a patient who has not received any professional services, i.e., E/M service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous 3 years. For example, if a professional component of a previous procedure is billed in a 3 year time period, e.g., a lab interpretation is billed and no E/M service or other face-to-face service with the patient is performed, then this patient remains a new patient for the initial visit. An interpretation of a diagnostic test, reading an x-ray or EKG etc., in the absence of an E/M service or other face-to-face service with the patient does not affect the designation of a new patient.

B. Office/Outpatient E/M Visits Provided on Same Day for Unrelated Problems As for all other E/M services except where specifically noted, the Medicare Administrative Contractors (MACs) may not pay two E/M office visits billed by a physician (or physician of the same specialty from the same group practice) for the same beneficiary on the same day unless the physician documents that the visits were for unrelated problems in the office, off campus-outpatient hospital, or on campus-outpatient hospital setting which could not be provided during the same encounter (e.g., office visit for blood pressure medication evaluation, followed five hours later by a visit for evaluation of leg pain following an accident).

C. Office/Outpatient or Emergency Department E/M Visit on Day of Admission to Nursing Facility MACs may not pay a physician for an emergency department visit or an office visit and a comprehensive nursing facility assessment on the same day. Bundle E/M visits on the same date provided in sites other than the nursing facility into the initial nursing facility care code when performed on the same date as the nursing facility admission by the same physician.

D. Drug Administration Services and E/M Visits Billed on Same Day of Service MACs must advise physicians that CPT code 99211 cannot be paid if it is billed with a drug administration service such as a chemotherapy or nonchemotherapy drug infusion code (effective January 1, 2004). This drug administration policy was expanded in the Physician Fee Schedule Final Rule, November 15, 2004, to also include a therapeutic or diagnostic injection code (effective January 1, 2005). Therefore, when a medically necessary, significant and separately identifiable E/M service (which meets a higher complexity level than CPT code 99211) is performed, in addition to one of these drug administration services, the appropriate E/M CPT code should be reported with modifier -25. Documentation should support the level of E/M service billed. For an E/M service provided on the same day, a different diagnosis is not required.

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