Wiki Cpt 99215

[padelson1]

My provider wants to charge 99215 for a ADD follow up, which was normal , and one new DX, L70.0 Acne, and DX L74.510 primary focal hyperhidrosis axilla. He did prescribe medication for new DX. However, I don't think CPT 99215 applies. The new DX are not moderate to high severity problem, and no additional workup was done. My provider think is a 99215 because of new DX. Can he bill as 99215 because of new DX for this visit. Please help

 

[twizzle]

My provider wants to charge 99215 for a ADD follow up, which was normal , and one new DX, L70.0 Acne, and DX L74.510 primary focal hyperhidrosis axilla. He did prescribe medication for new DX. However, I don't think CPT 99215 applies. The new DX are not moderate to high severity problem, and no additional workup was done. My provider think is a 99215 because of new DX. Can he bill as 99215 because of new DX for this visit. Please help

No, your provider cannot bill 99215 because he has to address a new problem. None of these pose a threat to life which, when it comes to the table of risk, is what is needed to use 99215. If he thinks your patient might expire due to acne or a sweaty axilla then he needs to document a good reason why he thinks that might happen.

2 established stable problems and 1 minor problem, new acute uncomplicated condition requiring a prescription med. Depending on the rest of the documentation he might be able to justify 99214 at best based on MDM.

 

[thomas7331]

Although 99215 does sound high given the limited information you've provided, no coder can say definitively that a visit does not qualify just based on this - one really needs to evaluate the entire note to make the right code determination. I'd refer you back to the E&M coding requirements in CPT for your answer to this question. To bill a 99215, the provider must have documented 2 of the 3 elements of: a comprehensive history, a comprehensive exam, high-level MDM. High-level MDM in turn is defined as met by 2 of these 3 categories: extensive diagnosis/management options, extensive data, and high risk. Additionally, the visit may qualify for 99215 based on time, if properly documented. I'd point out too that although some coders and auditors have a practice of requiring MDM to be met in order to bill a certain level, this is not an official practice and is not mandated by either CPT or CMS official guidelines.

Although some providers inflate documentation for simple problems to meet higher levels than are warranted, that is a medical necessity question which is separate issue and does not change the basic coding guidelines. The code choice should be made based on code description and after an evaluation of the provider's note, looking at the work performed and the documented assessment of the patient. I'd add too, in response to the previous post, that it's simply not true that a 99215 requires a problem that is a threat to life - although the risk is one element in determining overall MDM, that measure by itself does not qualify or disqualify any given code level.

 

[CodingKing]

99215's should be pretty rare, maybe 5% or so of all encounters. If every patient starts to become a 99215 be prepared for an audit. Make sure all of the requirements are met.

 

[padelson1]

Thank you, this helps alot.

 

[daedolos]

99215's should be pretty rare, maybe 5% or so of all encounters. If every patient starts to become a 99215 be prepared for an audit. Make sure all of the requirements are met.

There was a doctor in the rural Midwest that coded 95% of his visits with 99215 or 99205. Noridian knew about it for years and it finally stopped.

Peace
@_*
99215 should be for life threatening cases.

 

[mitchellde]

When you are looking at the coding guidelines, the guidelines indicated as "inpatient guidelines" such as coding possible, probably, suspected as an existing diagnosis, applies to the inpatient facility coder. They do not apply to the physician coder coding for inpatient visits. Physician guidelines (which are much the same as facility outpatient guidelines )apply to the physician services regardless of setting.