Ophthalmology and Optometry Coding Alert

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

Florida Subscriber

Answer: You would report 99215 (Office or other outpatient visit for the evaluation and management of an established patient ...) when your physician's documentation supports high complexity 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 more than half of the visit. Your doctor has to document this with total time, counseling time, details of the counseling, and the need for it.

An "extended" office visit does not mean anything without documentation to support history, exam, and medical decision making at that level as per the AMA/ CMS 1995 or 1997 E/M Documentation Guidelines.