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Wiki Coding a 99215

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kathymoon

kathymoon

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I have an internist that sees many geriatric patients. As I am reviewing his charts, he is charging a 99215. The patient is coming in for a 6-month or 1 year check up. He documents a comprehensive history and a comprehensive physical exam. He is covering 4 or more chronic conditions that are generally stable. He reviews labs but does not document the results. In one particular case, he covers 6 chronic conditions, refills medications and/or orders labs. Do you feel this visit can be considered a 99215? He is not documenting the time, or counseling time.

I'd like some opinions. Thanks.
 
Last edited:
kathymoon said:
I have an internist that sees many geriatric patients. As I am reviewing his charts, he is charging a 99215. The patient is coming in for a 6-month or 1 year check up. He documents a comprehensive history and a comprehensive physical exam. He is covering 4 or more chronic conditions that are generally stable. He reviews labs but does not document the results. In one particular case, he covers 6 chronic conditions, refills medications and/or orders labs. Do you feel this visit can be considered a 99215? He is not documenting the time, or counseling time.

I'd like some opinions. Thanks.
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This depends really on what your Medicare carrier considers a 99215!

Based on CPT guidelines, you have 2 of the 3 key elements for a 99215. So, if your MAC (such as Novitas) goes by those guidelines, than this would be a 99215. If your MAC is one of those that expects the MDM (not to be confused with Medical Necessity) to be the over all deciding factor, than this would only be a 99214. To have a high complexity MDM He would need to document at least 4 data points for amount and/or complexity of data reviewed as he has over 4 points for number of diagnoses with 4 or more stable diagnoses.
 
jdibble said:
This depends really on what your Medicare carrier considers a 99215!

Based on CPT guidelines, you have 2 of the 3 key elements for a 99215. So, if your MAC (such as Novitas) goes by those guidelines, than this would be a 99215. If your MAC is one of those that expects the MDM (not to be confused with Medical Necessity) to be the over all deciding factor, than this would only be a 99214. To have a high complexity MDM He would need to document at least 4 data points for amount and/or complexity of data reviewed as he has over 4 points for number of diagnoses with 4 or more stable diagnoses.
Click to expand...

The question would be was it medically necessary to perform a Comprehensive History and Exam. Say the patient has 4 stable chronic conditions and is coming in to have a splinter removed and a refill on a medication. I don't know how one could justify that high of a level.
 
I agree that this doesn't qualify for a 99215. There are no risk factors documented to raise it any higher than an 99214. As far as what my MAC approves, I believe it to be the 2 out of 3, but I agree that the physical exam must be medically necessary for the condition(s). I just wanted to see if I had missed anything. I actually read in some publication that if they had over 4 stable conditions this would qualify as a 99215. I had NEVER heard that before and definitely wasn't going to base my coding on that one article.

I know my provider needs to document his time and counseling time if he feels he spent the time to qualify for a 99215.

Appreciate your contributions to solidifying my conclusions. Thanks.
 
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