billing cpt code 99215


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.


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!"

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.


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


  • 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.






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.


Same Day Evaluation and Management Services

It may be necessary to provide evaluation and management (E/M) services on the same day as a drug administration procedure. Depending on the payer, E/M services that are medically necessary, separate, and distinct from the drug administration procedure (CPT® codes 99201-99205 and 99211-99215 in the physician office and HCPCS code G0463 in the hospital outpatient setting), and documented appropriately are generally covered. CMS has a specific policy regarding use of CPT® code 99211 (level 1 medical visit for an established patient) in the physician office:


For services furnished on or after January 1, 2004, do not allow payment for CPT® code 99211, with or without modifier 25, if it is billed with a non-chemotherapy drug infusion code or a chemotherapy administration code. Apply this policy to code 99211 when it is billed with a diagnostic or therapeutic injection code on or after January 1, 2005.9 This means that a level 1 medical visit for an established patient (99211) cannot be billed on the same day as an office-based therapeutic or complex infusion or injection.


• If the patient is seen for a single visit or encounter:

o One preventive medicine service (99381 – 99397) may be reported with one problem-oriented E/M Service, if the following criteria is met: When, in the process of performing a preventative medicine examination, a pre-existing problem is addressed or an abnormality is encountered and the problem/abnormality is significant enough to require the additional work of the key components of a problem-oriented E&M service, the problemoriented outpatient established patient E/M service code (99211 – 99215) with modifier 25 appended is eligible for separate reimbursement in addition to the preventive visit service. Note the documentation requirements previously mentioned above.


Billing Example

Treatment of Opioid Dependence shall consist of the following:

o Assessment and Treatment Planning
· 1 - 2 office visits.

· CPT code 90801 (used for psychiatrist. E&M services i.e. 99213 will be used by  internal medicine and other non-psychiatrist medical doctors. Psychiatrists may also useE&M codes to report treatment during the Assessment and Treatment Planning phase if an E&M is the most appropriate code to be filed for the services rendered).

o Induction
· 1 - 2 hour office visits.
· Average frequency and duration of 3 times/week for two weeks
· CPT code 99205 or 99215

o Stabilization
· 1 - 2 office visits/week.
· Average frequency and duration of 6 times/month for two months.
· CPT code = 90805 or 90862. May use 90807 when clinically indicated.

o Maintenance
· 1 office visit/month.
· CPT code = 90862.

Reimbursement and Coding:

There are no specific CPT codes for buprenorphine therapy. Most reported services directly related to buprenorphine therapy will be Evaluation and Management services (99201-99205, 99211-99215) or Pharmacologic Management (90862) if rendered by a psychiatrist. Initial assessments by psychiatrists may require behavioral health code (90801). Induction visits may require prolonged face-to-face visits (99201-99205 or 99211-99215 and 99354-99355).

There is no code for use of the office during observation periods, only face-to-face time by the physician is used when reporting prolonged services codes. Therefore, time must be carefully documented. Prolonged services codes require documentation review. BCBSRI does not cover medication management in a group. Group therapy services provided in conjunction with Suboxone treatment is a covered benefit when a professional eligible to be a BCBSRI-credentialed clinician is present at the group meeting. Participating providers may not charge members for covered services except as permitted for copayment, coinsurance, deductibles, and benefit limits.

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