# Picking E/M level code...



## TiffanyNH (Oct 26, 2009)

Hey guys I have a question...  When picking the level of E/M can someone tell me what do I HAVE to have to determine the level?  Ex:  I hv a 99215 code but in notes I hv no PFSH at all and only 8 ROS can I still code a 99215 for that?  I have the HPI complete and the medical decision making but nothing else...  What do you think?


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## FTessaBartels (Oct 26, 2009)

*Not 99215*

Tiffany,
For a comprehensive history you must have 4+ elements of HPI (or status of 3 chronic conditions if you are using the 1997 guidelines for your exam) - AND - a complete ROS (10+ systems reviewed and documented) - AND= a complete PFSH (at least 1 item in EACH category past medical, family and social history).

But your question is far more complex than just whether you have a comprehensive history. I recommend the following:

*CPT *professional edition (2009) Evaluation and Management (E/M) Services *Guidelines* begin on page 1 (green paper in my version) and outline all the various requirements for E/M coding.   The *Instructions for Selecting a Level of E/M Service* begin on page 5; *Determine the Extent of History Obtained *is on pg 7. 

*www.emuniversity.com *has a wealth of information as well on how to pick your level of service. 

Google *1997 E/M Guidelines *and *1995 E/M Guidelines*.  Print them out, study them, refer to them.  

For an established patient visit, 99215, you must have TWO out of three:
Comprehensive History, Comprehensive Exam, High Complexity MDM.  
OR you must have documentation that support coding based on time spent in counseling & coordination of care. 

Hope that helps.

F Tessa Bartels, CPC, CEMC


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