Wiki established patient level

[cshelton1956@comcast.net]

If the physician documents a comprehensive history, and comprehensive exam, and a moderate decision making, do I give a level 5 due to the two comprehensive history and exam? If the patient only has a rash and is given a prescription basically, but the two of the three components are met....Can I give a level 5 in this scenario?

 

[MelDS]

For an established patient you only need to meet 2 out of 3 components. If this is for a regular office visit, it would be 99215 or level 5. Before I'd assign this code, I'd double check the documentation to be sure that it meets all the criteria for comprehensive hx and exam. Was a complete review of systems or a general multi system exam given. Anything less than this would not be comprehensive. As for the hx, was a complete hx given? On an established patient, I wouldn't think a comprehensive hx would be needed. That is usually done when they establish care as a new patient. Not sure if this helps.

 

[MnTwins29]

Also keep in mind the necessity for this much work for a patient with this diagnosis. While per CPT coding guidelines, yes, this would meet the requirements for 99215, keep in mind that medical necessity is the "overarching criteria" for many payers and they may audit or even deny this code with this diagnosis. E/M codes are supposed to reflect the amount of work the physician did with this patient. Would a complete history and comprehensive examination be needed for an established patient with this diagnosis? Would the doctor take that much time to do a fully comprehensive exam? While I am not trying to say that he or she didn't do this, it is highly unlikely that those tasks would be required for this particular patient.