Ob-Gyn Coding Alert

Question: Can I use 99215 for an extended office visit?

Kansas Subscriber

Answer: You would report 99215 (Office or other outpatient visit for the evaluation and management of an established patient ...) when your ob-gyn documentation supports high complexity of medical decision making (along with a comprehensive history and/or exam). You can also report 99215 when, due to the presenting problem, extensive counseling and/or coordination of care dominates the visit. Your ob-gyn has to document this with details and the need for it.

An "extended" office visit does not mean anything without details about the context of why it is extended and that those circumstances follow E/M documentation guidelines.