# CPT 99215 Level of Exam



## cwilson3333 (Oct 18, 2012)

Not used to billing CPT 99215, but want to know if this visit would justify a 99215, based on the number of diagnoses and tx plan.  

Trigger Finger
Sciatica
Knee Pain
Hip Pain

Trigger finger injected
Xrays done of LSPine, Hip, Knee
Referral to Pain Doctor

I am even always leary about coding 99214's, so definitely worried about using a 99215.
I seem to have a mental block when it comes to choosing the level of exam so if anyone out there has a sure fire way of making that decision, I open for all suggestions.

Thanks to all,
CW


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## KDoerfler (Oct 18, 2012)

*99215*

Your MDM needs to be supported by a comprehensive History, Exam and Medical Deciaion Making, at least 2 out of 3 are necessary.  It does not seem supported with your question. 
If there is a procedure done with E/M, don't forget the -25 modifier.  Needs to be a significantly separate service.   Hope this helps.  Kate


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## Orthocoderpgu (Oct 19, 2012)

*This is not a 99215 due to MDM*

The code you chosen cannot be higher than the MDM component. Look at your Table of Risk. Basically, in order to justify High MDM you have to have  life, limb, organ, organ system on the line or being treated with high toxicity  Rx. I can tell you don't have a legitimate 99215 just by looking at the diagnosis' that were treated.


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## mitchellde (Oct 19, 2012)

cwilson3333 said:


> Not used to billing CPT 99215, but want to know if this visit would justify a 99215, based on the number of diagnoses and tx plan.
> 
> Trigger Finger
> Sciatica
> ...



I am just curious but is this the documentation or is it a summary you are providing.  
Because I am trying to figure out if you have a level of service to bill or is this just an encounter for the injection, and even then is there a procedure not for the injection?
To evaluate if this is a level of service , 99215 or other, We would need to see the complete note.  If what you have provided is the complete note, then I see nothing to code.


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## cwilson3333 (Oct 23, 2012)

*Cpt 99215*

No, this is definitely not the complete note.  I was just high-lighting the patient complaints.
Will resubmit this later for your review.

Thanks,
CW

And thanks to all that replied.


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