Ob-Gyn Coding Alert

Question: A fellow coder told me that for an established patient, I only need two out of three elements. Does that mean if I have a comprehensive history and a comprehensive exam, I can bill 99215 (Office or other outpatient visit ...)?

California Subscriber

Answer: Watch out. That thinking will probably ensure that you return money to the payer after an audit.

Anyone can take a history or perform an exam, but only the provider can take that information to come up with a plan. The level you report must be in keeping with care that is medically indicated. The physician would not normally need to provide a comprehensive history and/or exam for a problem of straightforward, low or moderate complexity for an established patient — even Medicare makes this distinction.

So while CPT^® does not state that medical decision-making (MDM) is one of the required elements, many payers request their money back when you don’t have MDM to support your E/M level. In other words, they downcode your claim because the presenting problems documented do not require the level of history and/or exam that you billed.