Leveling Up to Level 5 Visits: 99215 Coding and Compliance


Evaluation and Management (E&M) code 99215 is considered by most physicians as the “Holy Grail” for visit levels.

Many providers think that they are unable to code this level of service because they believe that their patients do meet the criteria from the Centers for Medicare & Medicaid Services (CMS) or Current Procedural Terminology (CPT 4). In my experience, this is especially prevalent for providers who are not in a specialty practice. As I posted yesterday, this is simply not true.

Many providers shortchange themselves–and leave money on the table–because they do not fully understand how to properly document a 99215. A patient does not have to be on the brink of critical care in order to warrant the coding and billing of a level 5 visit in the office.

Recent statistics show that 99215 is the second least popular code used to bill amongst internists, who chose it in only 5% of established office patients. I will again point providers to Medicare Advantage members, who are reviewed ongoing for chronic disease processes and, often, meet the criteria to bill and code a 99215 office visit.

CMS Expectations for 99215

In order to successfully bill and code a 99215, CMS has given clear guidance on their expectations from providers for these services. Primarily, medical necessity is the overarching criteria that drives all levels of service and 99215 is no different.

Medical necessity is determined by several key identifiers:

  • The patient’s condition upon arrival
  • Severity
  • Acuity
  • Number of presenting problems

CMS also indicates that it is appropriate and requires the billing and coding of the E&M level that supports the “Nature of the Presenting Problem” and the treatment thereof. A point to keep in mind is that although an E&M service may meet all the bullet points and code out to the highest level based on accurate documentation of key components of work, CMS considers it inappropriate to submit for payment a level of service where the management of that patient is not reflected in accordance of a code’s work requirments.


Other points to remember pertaining to established patient services are that 2 of the 3 key components must be fully documented in order to bill and code for levels 99212-99215. If counseling and/or coordination of care is the primary driver of the visit – (more than 50% of face-to-face time), then time can be considered as the overall criteria that supports the service level, including 99215, as long as it is properly documented in the medical record.

Documentation Criteria for “The Holy Grail” 99215

The following conditions must be present in order to bill and code for a 99215:

  • Nature of Problem: High Severity
  • Criteria
  • Extensive diagnoses or management options
  • Extensive amount or complexity of data to be reviewed
  • High risk of complications, morbidity, mortality
  • 99215 – 40 minutes (average)

The Keys to E&M Coding

The key components (elements of service) of E&M services are:

  • History
  • Examination
  • Medical decision-making

Comprehensive history – Documentation needed:

  • Chief complaint
  • Extended history of present illness
  • Complete review of systems
  • Complete past, family, and social history

Comprehensive examination – Documentation needed:

  • A general multi-system examination OR complete examination of single organ system and other symptomatic or related body area(s) or 8 or more organ system(s)

Medical decision making that is of high complexity- Documentation needed (2 of 3 below must be met or exceeded):

  • Extensive number of diagnoses or management options
  • Extensive amount and/or complexity of data to be reviewed
  • High risk of significant complications, morbidity and/or mortality

CMS Minds the Store

A recent claim sample from WPS Medicare obtained on the following states: Iowa, Kansas, Missouri, and Nebraska for Specialty 08 (Family Practice) that focused on billing, utilization, and/or documentation of a specific service. The probe included 100 claims with CPT code 99215 that were randomly selected for a prepayment review. Each provider included in the probe had five claims submitted for payment on their behalf. Out the 100 claims – a total of 61 claims were paid as initially submitted and 39 claims were denied for the following reasons:

  • Documentation not received
  • Documentation does not support the service billed
  • Billed services must meet the Medicare guidelines
  • Must Meet Physician’s Current Procedural Terminology (CPT) manual
  • Documentation should reflect the amount of work performed at the visit and support the level of service billed
  • There are three (3) key components (history, examination, and medical decision making) to be considered when selecting the appropriate level of E&M service
  • The duration of the visit is an ancillary factor and does not control the level of the service to be billed, unless more than 50 percent of the floor/unit time in the hospital is spent providing counseling or coordination of care
  • The extent of the counseling and/or coordination of care must be documented in the medical record
  • Service not documented in the medical records
  • Non-documented services included services for which no documentation was received for the date of service.
  • The service in question must be documented in the medical record as having been performed on the day the service was billed.
  • Documentation must be signed with either a legible hand written signature or an electronic signature by the rendering provider
  • Non-covered Service (Item or Service Excluded)
  • The service in question was denied as not covered by this payer (Medicare Part B) because the service is not payable under our claims jurisdiction

Road to Compliance

The chart from WPS Medicare reflects the service codes 99211 – 99215, for Specialty 08 – Family Practice – it looks at how E&M services for established patients are billed at a carrier level and at a national level (slightly higher than carrier level) to compare billing/coding patterns:

To view this graph on the WPS website, click on the chart.

Comparative Billing Report for J5 MAC (IA, KS, MO, NE) Specialty 08 (Family Practice) BETOS Category M1B (Office Visit – Established) Dates of Service: July – December 2011 Paid Dates: July – March 2012

One can see that 99215 has a low reporting status from internal medicine and on a national level is only slightly higher in reporting statistics than at a carrier level. I suggest running your provider statistics for your practice and do a comparison against this graph to gain a feel for how your providers are leveling on all visits, but especially tune into 99215/99205 to ensure alignment with CMS’ findings. If you over/under-utilize the 5’s, as I call them, it’s time to conduct your own internal audit to make sure that the documentation supports all services and that you neither leaving money on the table or up-coding for unsupported services.

Points to Remember

CMS has one clear goal and that is to process and pay claims correctly the first time they are received. CMS views up-coding and under-coding as errors and has methodology in place to aid in curtailing these patterns. Audit and review with providers at least twice a year at minimum to ensure and maintain proper documentation, billing and coding habits.

Maintenance of the Medical Record

The medical record should be complete and legible with a logical flow. It should also be dated and authenticated by the physician.

  • Documentation should support the intensity of the evaluation and/or treatment, including thought processes and the complexity of medical decision-making
  • The codes recorded on the Medicare claim should be supported by the documentation in the medical record
  • The patient’s progress including response to treatment, change in diagnosis and patient non-compliance should be documented

Lastly, remember – as long as you “bulletproof your documentation” and the nature of the presenting problem align with the severity of illness – it is absolutely correct and appropriate to bill a level 5 code. Don’t leave money on the table due to lack of knowledge.

For a more in-depth breakdown and clinical example of 99215 from E&M University to assist with documentation for billing and coding justification – please click on the following links:


Happy Coding!


(Part 1 of this of this two-piece series appeared on MedicalBillingandCoding.org yesterday.)