99215 CPT Code: Know Your Codes

July 5, 2020CPT Codes

99215 CPT Code Description

99215 CPT Code: Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and a high level of medical decision making. When using time for code selection, 40-54 minutes of the total time is spent on the date of the encounter. For services 75 minutes or longer, see ‘Prolonged Services’ i.e. CPT Codes 99354-99357.

An established patient is one who has received professional services from the physician/qualified health care professional or another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years. In the instance where a physician/qualified health care professional is on call for or covering for another physician/ qualified health care professional, the patient’s encounter will be classified as it would have been by the physician/qualified health care professional who is not available.

Office/Outpatient E/M Coding (99202-99215) Changes in 2021

Effective with the date of service Jan. 1, 2021, the American Medical Association (AMA), which holds copyright in CPT®, and the Centers for Medicare & Medicaid Services (CMS) implemented major revisions related to office and outpatient E/M codes 99201-99215 in 2021. For complete information regarding all CPT codes and descriptions, refer to the 2021 edition of Current Procedural Terminology, published by the AMA. The stated goals were reducing administrative burden, improving payment accuracy, and updating the code set to reflect current medical practice.

*CPT Code*	*History and/or Exam*	*MDM*	*Total Minutes*
99212	Medically appropriate	Straightforward	10-19
99213	Medically appropriate	Low	20-29
99214	Medically appropriate	Moderate	30-39
99215	Medically appropriate	High	40-54

History and/or Exam

The History and/or Examination portion of office/outpatient E/M guidelines explains that office and other outpatient E/M services include ‘a medically appropriate history and/or physical examination, when performed.’ ‘Medically appropriate’ means that the physician or other qualified healthcare professional reporting the E/M determines the nature and extent of any history or exam for a particular service. Please note that the code selection does not depend on the level of history or exam.

Medical Decision Making (MDM) for CPT Code 99215

Level of MDM (Based on 2 out of 3 Elements of MDM): High

Elements of Medical Decision Making

Number and Complexity of Problems Addressed	*Amount and/or Complexity of Data to be Reviewed and Analyzed*	Risk of Complications and/or Morbidity or Mortality of Patient Management
High 1 or more chronic illnesses with severe exacerbation, progression, or side effects of treatment; or 1 acute or chronic illness or injury that poses a threat to life or bodily function	Extensive (Must meet the requirements of at least 2 out of 3 categories) Category 1: Tests, documents, or independent historian(s) Any combination of 3 from the following: 1. Review of prior external note(s) from each unique source; 2. Review of the result(s) of each unique test; 3. Ordering of each unique test; 4. Assessment requiring an independent historian(s) or Category 2: Independent interpretation of tests* Independent interpretation of a test performed by another physician/other qualified health care professional (not separately reported); or Category 3: Discussion of management or test interpretation Discussion of management or test interpretation with external physician/other qualified health care professional/appropriate source (not separately reported)	High risk of morbidity from additional diagnostic testing or treatment Examples only: 1. Drug therapy requiring intensive monitoring for toxicity 2. Decision regarding elective major surgery with identified patient or procedure risk factors 3. Decision regarding emergency major surgery 4. Decision regarding hospitalization 5. Decision not to resuscitate or to deescalate care because of poor prognosis

*Each unique test, order, or document contributes to the combination of
2 or combination of 3 in Category 1

RVUs for CPT 99215

The following table shows the first-quarter 2021 and fourth-quarter 2020 total RVUs for CPT 99215. MPFS facility RVUs are often lower than non-facility (office) RVUs because when a physician provides services in a facility, the physician is responsible for fewer practice expenses. The final reimbursement amounts for E/M services will depend on more than just these RVUs.

CPT 99215	*Non-Facility*	*Facility*
2020 Q4 RVUs	4.11	3.15
2021 Q1 RVUs	5.33	4.27

One policy change in the 2019 MPFS final rule that got a large reaction from providers was a plan to pay a single rate, called a blended rate. In other words, Medicare intended to pay the same rate for new patient codes 99202, 99203, and 99204, regardless of which code was reported. Medicare was going to pay another single rate for established patient codes 99212, 99213, and 99214. Level-5 visits (99205, 99215) would have separate rates to reflect the increased complexity those codes represent.

We hope that this article has provided basic guidelines about the 99215 CPT code. If you are looking for overall billing and coding services you can refer to E2E Medical Billing Services. Our accurate and affordable billing services will eliminate billing and coding errors and will increase your practice collection. To know more about our medical billing and coding services, call us at 888-552-1290 or write to us at info@e2eMedicalBilling.com