99215 CPT Code Description
99215 CPT Code: Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a comprehensive history; a comprehensive examination; Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 40 minutes are spent face-to-face with the patient and/or family. Billing Instructions: Bill 1 unit per visit.
Level 5 Office Visit (99215)
The 99215 represents the highest level of care for established patients being seen in the office. Internists selected the 99215 level of care for only about 9% of established office patients in 2014. The Medicare allowable reimbursement for this level of care is $145.72 and it is worth 2.11 work RVUs. Usually the problems are of moderate to high severity.
Established Patient E/M: 2 of 3 Key Components
Office/outpatient E/M codes for an established patient, 99212-99215, require a visit to meet only 2 of the 3 key components listed to support the service level. The following table shows the key component requirements for the different established patient office/outpatient E/M code levels.
|99211||(Usually, the presenting problems are minimal)|
|99212||Problem focused||Problem focused||Straightforward|
|99213||Expanded problem focused||Expanded problem focused||Low complexity|
Coding Office Visits – Based on Time
An E/M office visit may be coded based solely on face-to-face time when more than half is devoted to counseling or coordination of care. CPT requirements for history, exam, and medical decision-making requirements do not have to be met. Be sure to document the total time spent and that more than half involved counseling or coordination of care, and describe the nature of the counseling or care coordination activities (e.g., “counseled patient regarding weight gain, daily food intake, and goal setting”). Choose your level of service according to CPT’s definitions of what is typical for each code.
|CPT Code||Typical Time|
99215 CPT Code Reimbursement
|CPT Code||Service Time||Medicare||Commercial|
|99212||10 minutes||$ 40.61||$ 90.00|
|99213||15 minutes||$ 68.10||$ 90.00|
|99214||25 minutes||$ 101.21||$ 90.00|
|99215||40 minutes||$ 136.57||$ 148.00|
* It’s important to note that CPT Code 99215 reimbursement rates vary by location, the insurance company, network status, panel, license, and more.
|CPT Code||Required Time||Estimated Payment|
(99212 + GPRO1)
(99213 + GPRO1)
(99214 + GPRO1)
(99215 + 99354-5)
Clinical Examples of 99215 CPT Code
Simply because the patient’s complaints, symptoms, or diagnoses match those of a particular clinical example, does not automatically assign that patient encounter to that particular level of service. The three key components (history, examination, and medical decision-making) must be met and documented in the medical record to report a particular level of service.
- Office visit for an established patient who developed a persistent cough, rectal bleeding, weakness, and diarrhea plus pustular infection on the skin. Patient on immunosuppressive therapy. (Dermatology)
- Office visit for an established patient with progressive dermatomyositis and recent onset of fever, nasal speech, and regurgitation of fluids through the nose. (Dermatology)
- Office visit with a 30-year-old male established patient for a three-month history of fatigue, weight loss, intermittent fever, and presenting with diffuse adenopathy and splenomegaly. (Family Medicine)
- Office visit for a 70-year-old female, established patient, with diabetes mellitus and hypertension, presenting with a two-month history of increasing confusion, agitation, and short-term memory loss. (Family Medicine/Internal Medicine)
For accurate medical billing, knowing your CPT codes is the most important thing. In our blog series of ‘Know Your Codes’ or ‘KYC,’ we have discussed the most common CPT codes in detail and when to use them. E2E Medical Billing Services is known for it’s accurate and affordable medical billing services. To know more about our medical billing services call us at 888-552-1290 or write to us at info@e2eMedicalBilling.com