Results 1 to 2 of 2

Picking E/M level code...

  1. #1
    Exclamation Picking E/M level code...
    Medical Coding Books
    Hey guys I have a question... When picking the level of E/M can someone tell me what do I HAVE to have to determine the level? Ex: I hv a 99215 code but in notes I hv no PFSH at all and only 8 ROS can I still code a 99215 for that? I have the HPI complete and the medical decision making but nothing else... What do you think?

  2. #2
    Location
    Milwaukee WI
    Posts
    4,466
    Default Not 99215
    Tiffany,
    For a comprehensive history you must have 4+ elements of HPI (or status of 3 chronic conditions if you are using the 1997 guidelines for your exam) - AND - a complete ROS (10+ systems reviewed and documented) - AND= a complete PFSH (at least 1 item in EACH category past medical, family and social history).

    But your question is far more complex than just whether you have a comprehensive history. I recommend the following:

    CPT professional edition (2009) Evaluation and Management (E/M) Services Guidelines begin on page 1 (green paper in my version) and outline all the various requirements for E/M coding. The Instructions for Selecting a Level of E/M Service begin on page 5; Determine the Extent of History Obtained is on pg 7.

    www.emuniversity.com has a wealth of information as well on how to pick your level of service.

    Google 1997 E/M Guidelines and 1995 E/M Guidelines. Print them out, study them, refer to them.

    For an established patient visit, 99215, you must have TWO out of three:
    Comprehensive History, Comprehensive Exam, High Complexity MDM.
    OR you must have documentation that support coding based on time spent in counseling & coordination of care.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

Similar Threads

  1. Diagnosis for skin picking
    By Tarheelcoder in forum Behavioral Health
    Replies: 0
    Last Post: 09-24-2015, 05:49 AM
  2. Steadman Picking Procedure
    By ortholg@yahoo.com in forum Orthopaedics
    Replies: 2
    Last Post: 10-21-2013, 05:53 PM
  3. Picking a level code-HELP
    By sara0014 in forum E/M
    Replies: 3
    Last Post: 09-25-2013, 08:29 AM
  4. Picking E/M codes
    By bprater in forum Medical Coding General Discussion
    Replies: 0
    Last Post: 06-02-2013, 08:19 PM
  5. Picking level/elements of E/M
    By cwilson3333 in forum E/M
    Replies: 2
    Last Post: 02-20-2012, 03:53 PM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
  •  
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?

Login

Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.