Leveling Up to Level 5 Visits: 99205 Coding and Compliance


Patient providers have been reporting an increased frequency of higher-level evaluation and management (E&M) services and pushing up payments to $33.5 billion, according to a report released by the Department of Health and Human Services (HHS) and the Office of the Inspector General (OIG).

Level 5 E&M visits have jumped 48 percent, or $11 billion, since 2010, according to the Centers for Medicare & Medicaid Services (CMS). Higher-level E&M services codes are also being used over all other E&M codes.

The OIG was able to track these findings by utilizing the Part B Analytics Reporting System, which allowed investigators to review coding trends from 2001-2010. The review, titled “Coding Trends of Medicare Evaluation and Management Services,” found 1,700 unnamed physicians “who consistently billed higher-level E&M codes.” The OIG indicated that the physicians had what appeared to be aberrant coding and billing practices for these high level E&M codes, did so in about 95% of the visits they submitted, and is the main reason that the OIG now has them in their cross hairs for an audit.

The OIG issued three recommendations to CMS in light of these findings in order to facilitate corrective action with these providers prior to any audits:

  • Continue to educate physicians on proper billing for E&M services.
  • Encourage Medicare contractors to review physicians’ billing for E&M services.
  • Review physicians who bill higher-level E&M codes for appropriate action.

The OIG and CMS are focusing its corrective action of providers who are clearly abusing the system. Physicians should continue to utilize level 5 codes in their practices and file proper documentation to support the service.

I work with a lot of primary care physicians (PCP)–on average about 75 percent of visits are established office visits with billed and coded services that revolve around E&M codes: 99211–99215. In contrast, approximately 15 percent are new office visits with billed and coded services that revolve around E&M codes 99201–99205. The remaining 10 percent of office visits I regularly see are divided between hospital visits, procedures, or lab work.

I advise my providers to use the “nature of the presenting problem” as their guiding principle for choosing a level 5 E&M code. The severity of the problem should drive the level and leave no doubt–or money on the table. Typically, a level 5 visit presents with one or more chronic illnesses with severe exacerbation or a severe side effect of treatment.

Generally, PCPs do not bill or code for a lot of 99205s/99215s, but that doesn’t mean that a PCP can’t choose one of those codes. If the visit is appropriate for that level of service and has bullet proof documentation to support that level five, then the provider can choose it. Physicians who don’t have a good understanding of Current Procedural Terminology (CPT) or who don’t employ certified billing and coding professionals, can be losing 10–15 percent of revenue annually as a result.

Breaking Down A Level 5 New Patient Visit

Documentation requirements of a 99205: All three key components must be met

  • minimum of one item each from the past history, family history and social history (PFSH)
  • history that includes at least four elements of the history of present illness, or HPI (location, quality, severity, duration, timing, context, modifying factors and associated symptoms)
  • minimum 10-system review of systems (ROS)
  • A comprehensive exam – either a general multisystem exam or a complete single-organ-system exam

The 9921x series requires history or exam. The 9920x series requires history and exam

What’s in the History

The HPI is the timeline and description of the development of the current illness that the patient is presenting for and includes the first sign/symptom and may include the following:


• Quality
• Severity
• Duration
• Timing
• Context
• Modifying factors
• Associated signs and symptoms
• The status of chronic or inactive conditions

Review of Systems

• Constitutional symptoms (e.g., fever, weight loss)
• Eyes
• Ears, nose, mouth, throat
• Cardiovascular
• Respiratory
• Gastrointestinal
• Genitourinary
• Musculoskeletal
• Integumentary
(skin and/or breast)
• Neurologic
• Psychiatric
• Endocrine
• Hematologic/lymphatic
• Allergic/immunologic

Past, Family and/or Social History:

Past History

  • A review of current medications
  • prior illnesses and injuries, operations and hospitalizations
  • allergies and age-appropriate immunization status

Family History

  • A review of significant medical information about the patient’s family
  • health status or cause of death of parents, siblings and children
  • specific diseases related to problems identified in the CC, HPI or ROS

Social History

  • marital status
  • living arrangements
  • occupational history
  • use of drugs, alcohol or tobacco
  • extent of education
  • sexual history

View of a potential Level 5 Soap Note

I am a tactile person and learning goes the same way for me. I need to see it and do it to understand it. Soapnote.org has a great tool for new and established visits and the following is a quick view of the elements that comprise a level 5 New patient visit:

New Visit 99205

Three sections: History, Examination, and Medical Decision Making. For a new visit, the lowest scoring section determines the level.

Section 1: History
Notes: A documented chief complaint is mandatory to bill above a 99201. For the history section, the lowest level of the three subsections determines the billing level.

History of Present Illness
4 or more elements/3 chronic diseases (99205)
Location (example: left leg); Quality (example: aching, burning, radiating pain); Severity (example: 10 on a scale of 1 to 10); Duration (example: started three days ago); Timing (example: constant or comes and goes); Context (example: lifted large object at work); Modifying factors (example: better when heat is applied); and Associated signs and symptoms (example: numbness in toes).

Review of Systems
10 or more elements/negative (99205)

Elements: Constitutional symptoms (e.g., fever, weight loss); Eyes; Ears, Nose, Mouth, Throat; Cardiovascular; Respiratory; Gastrointestinal; Genitourinary; Musculoskeletal; Integumentary (skin and/or breast); Neurological; Psychiatric; Endocrine; Hematologic/Lymphatic; and Allergic/Immunologic

Past, Family, and Social History
2 or more elements (99205)

Elements: Past medical history, Family history, Social history

Section 2: Examination

CMS Table of examination elements
comprehensive (99205)
(more than 12 )

Elements are bulleted under these organ systems: Cardiovascular; Ears, Nose, Mouth and Throat; Eyes; Genitourinary (Female); Genitourinary (Male); Hematologic/Lymphatic/Immunologic; Musculoskeletal; Neurological; Psychiatric; Respiratory; and Skin

Section 3: Medical Decision Making (MDM)
The second highest (or median) level of the three subsections determines the billing level.

Number of Diagnoses or Management Options
Extensive (99205)

Guide: 4 or more Diagnoses/chronic diseases = Extensive

Medical Decision Making: Amount of Data
4+ (99205) / number of diagnostic tests ordered or reviewed

Risk of Complications, Morbidity, or Mortality
High (99205)

To practice coding soapnotes from soapnote.org, please click on the following link:

The Takeaway on Leveling Up

There is a “Level 5 Myth” circulating out there, which seems to lend itself to the fact that unless your practice is a specialty practice, a level 5 visit, whether new or established is unobtainable for PCPs. This is simply not true.

Anyone who is familiar with Medicare Advantage plans and Risk Adjustment/HCC coding can speak to that directly. I have personally seen numerous charts documented by a provider where the new patient is an elderly male or female who presents with the following chronic conditions: diabetes with a manifestation, hypertension, coronary artery disease, CHF with a new onset of dizziness, sweating and arrhythmia.

In order for the provider to assess and treat the NOPP (nature of the presenting problem), the provider has to complete a work up that requires a comprehensive history and comprehensive exam with high complexity decision making. In short, this equates to a level 5 new patient visit.

As long as the provider documents accordingly and specifically, in essence bulletproofing their documentation, there is nothing to worry about. Yes, you may get audited, but if you follow the guiding principles described in this post, you can stand behind with anything that might be questioned and remain worry-free.

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Happy Coding!