99215 CPT code falls the evaluation and management of part B established patient category.
A medically authentic history and examination and a high level of medical decision-making must assess and manage an established patient in an office or other outpatient setting.
When using the time to select a code, the date of the encounter takes up 40 – 54 minutes of the overall time. Use Prolonged Services, i.e., CPT Codes 99354 – 99357, for services lasting 75 minutes or more.
99215 CPT Code Description
Within the last three years, a settled patient has received professional services from the physician/qualified medical provider or another physician/qualified medical provider of the same specialty and subspecialty member of the same group setting.
Therefore, when a physician/qualified health care professional is on call or filling in for another physician/skilled health care professional, the patient’s interaction will be classed as if that physician/qualified health care professional had been present.
99215 CPT Code Components
Chief Complaint (CC): is a brief statement that explains the symptom, problem, condition, diagnosis, or reason for the patient encounter.
History of Present Illness (HPI): is a chronological description of the development of the patient’s current illness progression from the first sign and symptom or the prior encounter to the present.
HPI elements are Location, Quality, Severity, Duration, Timing, Context, Modifying Factors, and Associated signs & symptoms.
Review of Systems (ROS): is bodily of body systems collected by asking questions to identify signs or symptoms.
The three sorts of ROS (review of systems) are problem pertinent, extended, and complete.
The following schemes are helpful for ROS purposes: Constitutional Symptoms (for example, fever, weight loss), Eyes, Ears, nose, mouth, throat, Cardiovascular, Respiratory, Gastrointestinal, Genitourinary, Musculoskeletal, Integumentary (skin or breast), Neurological, Psychiatric, Endocrine, Hematologic/lymphatic, Allergic/immunologic.
Past, Family, or Social History (PFSH): consists of a review of three areas:
It includes a history of diseases, procedures, injuries, and treatments.
Family history contains a review of medical experiences, diseases, and hereditary conditions that may put the patient at risk.
A social history contains a summary of age-appropriate past and present activities.
Physical Examination: The levels of E/M services depend on four types of examination:
Problem Focused: A narrow evaluation of the damaged body area or organ system.
Expanded problem focused: It describes a constrained assessment of the affected body site or organ system.
Detail: A thorough examination of the afflicted body area(s) or organ system(s) as well as any other symptomatic or connected body area(s) or organ system.
Comprehensive: A broad multi-system examination or complete examination of a particular organ system (and another symptomatic or related body area (s) or organ system(s) – 1997 documentation guidelines).
The physician may determine the breadth and scope of the analysis by clinical judgment, the patient’s history, and the nature of the presenting condition(s).
Medical Decision Making:
Medical decision-making refers to the problem of establishing a diagnosis or selecting a treatment choice.
One may consider the following factors:
- Evaluation of the number of probable diagnoses or management choices,
- One must gather, review, and analyze diagnostic tests, medical records, or other information.
99215 CPT Code Billing Guidelines and Reimbursement Policy
The code sets used to bill for E/M services are classified and leveled. The higher the degree of code you may charge within the proper category, the more complex the visit is.
The services provided must fulfill the code’s definition to set any code.
Therefore, it would be best to verify that the chosen principles accurately reflect the services provided.
History, examination, and medical decision-making are the three most essential factors in determining the appropriate amount of E/M services provided.
Pay special attention to the entries for time and services reported separately, according to the 2021 CPT E/M rules.
The coder does not consider the history and physical exams while coding.
However, according to the code specifications, state physicians must deliver a medically suitable history and examination.
Physicians might choose to document medical decision-making (MDM) or total time.
The three existing MDM sub-components have not undergone any substantial modifications.
Therefore, the two forms of PFSH are both pertinent and complete.
Instead of ordinary time, time may now be described as minimal time, indicating the total time spent on the day of service or a qualified health care professional (QHP).
The DOS time is consistent with Medicare’s initiatives to properly recognize the work in non-face-to-face services such as care coordination.
Selecting an appropriate modifier as per the situational requirement is the key to maximizing the first pass ratio of claims.
The key to maximizing the first pass ratio of shares is to choose the proper modification based on the scenario.
99215 CPT Code Modifiers
Modifiers 25 narrated as a significant, separately identifiable E/M service provided by the same physician on the same DOS.
It may be essential to clarify that on the day a procedure was performed, the patient’s condition entailed a significant, separately identifiable E/M service above and extreme the other service provided.
Telehealth modifiers such as 95 and GT are also appropriate with 99215 CPT code when the physician performs the service over the phone. The POS for all outpatient consultations is 02.
In circumstances where the encounter comes during the global period of any surgical operation, append modifier 24 with 99215 CPT code.
According to the coding guideline, the global period is 10 or 90 days.
Therefore, if the patient obtains any evaluation and management throughout that global time, the coder may submit it with modifier 24.
Both minor and major surgical procedures are inclusive. Insurance may not pay separately as part of the surgical treatment.
If a physician provides services in an unlisted health professional shortage region, use modifier AQ to higher compensation.
99215 CPT Code Examples
E&M services or consultation is often best described with the help of examples.
Final Office Appointment with Transfer Planning of a Medically Complex Young Adult Office visits with a 20-year-old female patient with spastic quadriplegia related to cerebral palsy.
She has epilepsy and requires a motorized wheelchair for movement, an iPad for communication, and a gastrostomy tube for nourishment.
In addition, she has legal paperwork that allows her mom to be there in the room with her.
The physician spends almost 40 minutes with the patient at this routine chronic care appointment, assessing her degree of preparedness for an adult model of care using a scorable transfer readiness assessment form, reviewing the enteral formula, and reconciling her seizure medication.
The physician discusses the transfer duration with the young adult and parent and coordinates transfer plans with her other physicians.
The pediatrician phones the new adult physician on the appointment day to inform him about the impending transfer and discusses the medical status for 20 minutes.
It includes preparing the transfer letter, contacting the young adult’s other specialists to coordinate transfer information, consulting with the new adult doctor, and calling the young adult to review the final transfer plans, including the date for the initial adult appointment.
In this case, the coder will code the claim: CPT 99215 as the primary code (describes as an office visit, established patient, high level of medical decision-making, or 40-54 minutes), then CPT 99417 (Prolonged office visit on the same day for every 15 minutes), CPT 96160 (describes as health risk assessment instrument focused on a patient), and CPT 99487 (describes as complex care management service – chronic patient for 60 minutes).
For eligible diagnosis, the coder will use ICD – 10 CM: G40.90 (Epilepsy, unspecified, not intractable), G80.0 (Gastrostomy status), Z93.1 (Spastic quadriplegic cerebral palsy).
Adult and Pediatric Primary Care Physicians Consult Interprofessional Following a patient’s second visit to the adult general care physician, the adult primary care physician requested an interprofessional consultation with the patient’s previous pediatric physician on this 19-year-old with an established diagnosis of ADHD.
The young adult comes to the adult physician with his mother to review his pharmacologic management of ADHD.
The adolescent has signed a HIPAA form allowing his mother to accompany him during the session.
The last appointment had resulted in the adult physician prescribing a new prescription, Adderall XR, but the young adult’s attention had not improved.
For this interprofessional consultation, the adult physician speaks by phone with the pediatric consulting physician, stating that there has been minor improvement in the clinical course since adding Adderall XR 10 mg one month ago.
The adult primary care physician reviewed the patient’s (a college freshman) and mother’s inattention, hyperactivity, forgetfulness, and ongoing organizational problems.
The patient denies experiencing any adverse effects from his medicine.
Psychosocial pressures are not acknowledged. Pickup basketball is one of the patient’s recreational interests, and he reports sleeping 6 hours each night.
The consultant pediatrician spends 25 minutes on the phone with the adult physician reviewing the patient and offering advice on pharmacologic and behavioral care and the significance of proper sleep.
During this time, the pediatrician dictates to submit a consultation report to the adult doctor, and the adult doctor contacts the patient with suggestions.
The total physician time was 50 minutes, including 25 minutes of face-to-face contact with the patient and 25 minutes of interprofessional consultation.
The coder will code for the adult physician. If the young adult’s face-to-face E/M visit coincided with the interprofessional consultation with the pediatric physician, then the coder will code the claim as:
First use CPT 99215 (office visit, established patient, high degree of medical decision making, or 40-54 minutes; total physician time was 50 minutes – 25 minutes face-to-face with the patient and 25 minutes for interprofessional consultation).
And then ICD-10 CM is F90.2 (attention-deficit hyperactivity disorder, combined type).
More CPT Code 99215 Examples
The following are examples of when 99215 CPT code may be used.
Office visit for an established patient who developed persistent cough, rectal bleeding, weekness, and diarrhea plus pustular infection on skin. Patient on immunosuppressive therapy. (Dermatology)
Office visit for an established patient with disseminated lupus erythematosus, extensive edema of extremities kidney disease, and weakness requiring monitored course on azathioprene, corticosteroid and complicated by acute depression. (Dermatology/Internal Medicine/Rheumatology)
Office visit for an establihed patient with progressive dermatomyositis and recent onset of fever, nasal speech, and requrgitation of fluids through the nose. (Dermatology)
Office visit for a 28-year-old female, established patient, who is abstinent from previous cocaine dependence but reports progressive panic attacks and chest pains. (Psychatry)
Office visit for an established adolescent patient with history of bipolar disorder treated with lithium; seen on urgent basis at family’s request because of server depressive symptoms. (Psychiatry)
Office visit for an established patient having acute migraine with new onset neurological symptoms and whose headaches are unresponsive to previous attempts at management with a combination of preventive and abortive medication. (Pain Medicine)
Office visit for an established patient with exfoliative lichen planus with daily fever spikes, disorientation, and shortness of breath. (Dermatology)
Office visit for a 25-year-old, established patient, two years post-burn with bilateral ectropion, hypertrophic facial bourn scars, near absence of left breast, and burn syndactyly of both hands, Discussion of treatment options following examination. (Plastic Surgery)
Office visit for a 6-year-old, established patient, to review newly diagnosed immune deficiency with recommendation for therapy including IV immunoglobulin and chronic antibiotics. (Allergy & Immunology)
Office visit for a 36-year-old, established patient, three-month status post-transplant, with new onset of peripheral edema, increased blood pressure, and progressive fatigue. (Nephrology)
Office visit for an established patient with kaposi’s sarcoma who presents with fever and widespread vesicles. (Dermatology)
Office visit for a 27-year-old female, established patient, with bipolar disorder who was stable on lithium carbonate and monthly supportive psychotherapy but now has developed symptoms of hypomania. (Psychiatry)
Office visit for a 25-year-old male, established patient with a history of schizophrenia who has been seen bi-monthly but is complaining of auditory hallucinations. (Psychiatry)
Office visit for a 62-year-old male, established patient, three years postoperative abdominal perineal resection, now with a rising carcinoembryonic antigen, weight loss, and pelvic pain. (Abdominal Surgery)
Office visit for an 42-year-old male, established patient, nine months postoperative emergency vena cava shunt for varicealbleeding, now present with complaints of one episode of “dark” bowel movement, weight gain, tightness in abdomen, whites of eyes seem yellow and occasional drowsiness after eating hamburgers. (Abdominal Surgery)
Office visit for a 68-year-old male, established patient, with biopsy-proven rectal carcinoma, for evaluation and discussion of treatment options. (General Surgery)
Office visit for a 60-year-old, established patient, with diabetic nephropathy with increasing edema and dyspnea. (Endocrinology)
99215 CPT Code Example 18
Office visit with 30-year-old male, established patient for three-month history of fatigue, weight loss, intermittent fever, and presenting with diffuse adenopathy and splenomegaly. (Family Medicine)
99215 CPT Code Example 19
Office visit for restaging of an established patient with new lymphadenopathy one year post-therapy for lymphoma. (Hematology/Oncology)
99215 CPT Code Example 20
Office visit for evaluation of recent onset syncopal attacks in a 70-year-old female, established patient. (Internal Medicine)
99215 CPT Code Example 21
Follow-up visit, 40-year-old mother of three, established patient, with acute rheumatoid arthritis, anatomical Stage 3, ARA function. (Rheumatology)
99215 CPT Code Example 22
Follow-up office visit for a 65-year-old male, established patient, with a fever or recent onset while on outpatient antibiotic therapy for endocarditis. (Infectious Disease)
99215 CPT Code Example 23
Office visit for a 75-year-old, established patient, with ALS (amyotrophic lateral sclerosis), who is not longer able to swallow. (Neurology)
99215 CPT Code Example 24
Office visit for a 70-year-old female, established patient, with diabetes mellitus and hypertension, presenting with a two-month history of increasing confusion, agitation, and short-term memory loss. (Family Medicine/Internal Medicine)