99215

Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter.

CPT code 99215 represents an office or other outpatient evaluation and management (E/M) service for an established patient. This service requires a medically appropriate history and/or examination, and a high level of medical decision making (MDM). When using total time on the date of the encounter for code selection, 40-54 minutes must be spent by the physician or other qualified healthcare professional. This includes both face-to-face and non-face-to-face time (e.g., reviewing records, ordering tests, communicating with other professionals, counseling, documenting). The high MDM level typically involves multiple acute or chronic illnesses, exacerbations of chronic illnesses, new problems with severe threat to life or bodily function, or extensive review of data and management options.

Clinical Indications

  • Management of new or established problems posing a severe threat to life or bodily function (e.g., severe exacerbation of COPD, unstable angina, acute stroke symptoms).
  • Patients with multiple severe chronic illnesses that are poorly controlled or require significant adjustments in management (e.g., uncontrolled diabetes with complications, advanced heart failure, end-stage renal disease).
  • Complex diagnostic problems requiring extensive workup, differential diagnoses, and management planning (e.g., new onset neurological deficits, unexplained weight loss, suspected malignancy).
  • Situations requiring extensive review of external records, images, pathology reports, and extensive discussion of management options with the patient and/or family.
  • Patients requiring extensive counseling and coordination of care due to the severity or complexity of their condition.

Procedure Steps

  1. Obtain and document a medically appropriate history, focusing on the chief complaint, history of present illness, and relevant past medical, family, and social history.
  2. Perform and document a medically appropriate physical examination, targeted to the patient's presenting problems and relevant systems.
  3. Perform a high level of medical decision making, which includes addressing at least one element from each of the following categories: 1) Number and complexity of problems addressed (e.g., multiple severe problems, one acute or chronic illness or injury that poses a severe threat to life or bodily function); 2) Amount and/or complexity of data to be reviewed and analyzed (e.g., extensive review of outside records, ordering and interpreting complex imaging/labs/tests, independent interpretation of tests, discussion of management with external physician or other qualified health care professional); 3) Risk of complications and/or morbidity or mortality of patient management (e.g., extensive prescribing of high-risk drugs, decision for emergent surgery, treatment of decompensated or unstable conditions).
  4. Develop and document a comprehensive management plan, including further diagnostics, therapeutic interventions, referrals, and patient education.
  5. Provide extensive counseling and/or coordination of care commensurate with the complexity of the patient's condition, if time is used for code selection.
  6. Document the total time spent on the date of the encounter, if time is the controlling factor for code selection, detailing the activities performed.

Coding Guidelines

  • CPT 99215 is for an established patient. An established patient is one who has received professional services from the physician or another physician of the exact same specialty and subspecialty in the same group practice within the past three years.
  • Code selection for E/M services (99202-99499) is based on either the level of Medical Decision Making (MDM) or the total time spent on the date of the encounter. For 99215, the MDM must be High, OR 40-54 minutes of total time must be documented.
  • For MDM-based coding, all three elements of MDM (number and complexity of problems, amount and/or complexity of data, and risk of complications/morbidity/mortality) are considered, and two out of three must be met or exceeded to qualify for a given level.
  • For time-based coding, the total time includes all physician/other qualified healthcare professional time on the date of the encounter, including non-face-to-face activities like reviewing prior records, ordering and interpreting tests, communicating with other providers, counseling, and documenting.
  • Documentation must clearly support the chosen level of service, whether by MDM or time. If MDM is used, the complexity of problems, data review, and risk should be evident. If time is used, the specific activities performed and the total time must be recorded.
  • Do not report 99215 if the primary reason for the encounter is a procedure with a global period that includes the E/M service. If a significant, separately identifiable E/M service is performed on the same day as a minor procedure, modifier 25 may be appended to 99215.

Associated ICD-10 Codes