Pediatric Coding Alert

Question: My pediatrician spent 42 minutes with a patient who presented with a slight fever, sore throat, and nasal congestion. The patient tested negative for COVID-19 and has a history of seasonal allergies. The official diagnosis was allergic rhinitis. The pediatrician told me the time spent justifies reporting the visit as a 99215. However, I disagree. Am I incorrect?

Michigan Subscriber

Answer: You are probably correct. If the patient record states that the patient had the symptoms you described, tested negative for COVID, has a clear history of allergies, and the diagnosis is straightforward, the 42-minute encounter is going to raise some red flags with the payer. Those details make the encounter look simple and low-risk. To prove medical necessity for an evaluation and management (E/M) level as high as 99215 (Office or other outpatient visit for the evaluation and management … high level… 40-54 minutes of total time…), you’ll need to submit significant documentation that would explain why the visit took so long. It is possible there was a legitimate explanation for a 42-minute encounter, but without detailed documentation from the provider, the payer will deny the claim.