Part B Insider (Multispecialty) Coding Alert

Question: When we have an established patient that comes into our office that needs to be sent to the hospital, we don’t perform a complete review of systems. Will these be level 4 or 5 established patient office visits?

Answer: As with other visits, you should determine the code selection by the visit’s documentation. You can give credit if a portion of the history was unable to be obtained because of the emergent nature of the patient’s conditions, as long as the physician indicates that within his note. 

To report 99214 (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 detailed history; a detailed examination; medical decision making of moderate complexity…), you need detailed history and MDM. For the 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 need comprehensive history and MDM. 

Check the exam: Without the complete history, if the medical decision-making (MDM) is high or moderate, the weight of the visit would be measured with the content of the exam and MDM because established patient encounters only require you meet two of the three elements; therefore, it wouldn’t matter what history elements might be missing. If you have the exam and MDM to support 99214 or 99215, you can report that code despite the lack of history.