Part B Insider (Multispecialty) Coding Alert
Reader Question:
99215 Won't Always Apply When Documentation Says 'Extended Visit'
Published on Tue May 17, 2011
Question:
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 the visit. Your doctor 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.
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