Neurology & Pain Management Coding Alert

Question: To bill a 99215 visit, can I have a comprehensive history, comprehensive exam, and medical decision making of low complexity?

Virginia Subscriber

Answer: To meet the CPT requirements to bill 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 ...), you only need to meet the level of any two of the three key components as stated.

"Two comps and a low," as in the original question, do qualify for 99215. However, most payers have requirements stating that in order to be considered for payment, all services must meet medically necessary criteria. It would be uncommon for a patient's condition to require your neurologist to perform a comprehensive history and physical exam when his findings only meet the low complexity criteria.

Also note: The code descriptor clearly states "which requires," which is not synonymous with your neurologist performing the "extra work" in the history and exam section to just meet the criteria for a higher E/M level.

Reminder: The "at least 2 of these 3 key component" criteria is a constraint for follow-up or established patients but not new patient visits or consultations, which require all three key components be met.