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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
    Milwaukee WI
    Default Not 99215
    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. 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

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