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Clinical Examples for 99215


Office visit for an established patient who developed persistent cough, rectal bleeding, weekness, and diarrhea plus pustular infection on skin. Patient on immunosuppressive therapy. (Dermatology)

Office visit for an established patient with disseminated lupus erythematosus, extensive edema of extremities kidney disease, and weakness requiring monitored course on azathioprene, corticosteroid and complicated by acute depression. (Dermatology/Internal Medicine/Rheumatology)

Office visit for an establihed patient with progressive dermatomyositis and recent onset of fever, nasal speech, and requrgitation of fluids through the nose. (Dermatology)

Office visit for a 28-year-old female, established patient, who is abstinent from previous cocaine dependence but reports progressive panic attacks and chest pains. (Psychatry)

Office visit for an established adolescent patient with history of bipolar disorder treated with lithium; seen on urgent basis at family’s request because of server depressive symptoms. (Psychiatry)

Office visit for an established patient having acute migraine with new onset neurological symptoms and whose headaches are unresponsive to previous attempts at management with a combination of preventive and abortive medication. (Pain Medicine)

Office visit for an established patient with exfoliative lichen planus with daily fever spikes, disorientation, and shortness of breath. (Dermatology)

Office visit for a 25-year-old, established patient, two years post-burn with bilateral ectropion, hypertrophic facial bourn scars, near absence of left breast, and burn syndactyly of both hands, Discussion of treatment options following examination. (Plastic Surgery)

Office visit for a 6-year-old, established patient, to review newly diagnosed immune deficiency with recommendation for therapy including IV immunoglobulin and chronic antibiotics. (Allergy & Immunology)         

Office visit for a 36-year-old, established patient, three-month status post-transplant, with new onset of peripheral edema, increased blood pressure, and progressive fatigue. (Nephrology)

Office visit for an established patient with kaposi’s sarcoma who presents with fever and widespread vesicles. (Dermatology)

Office visit for a 27-year-old female, established patient, with bipolar disorder who was stable on lithium carbonate and monthly supportive psychotherapy but now has developed symptoms of hypomania. (Psychiatry)

Office visit for a 25-year-old male, established patient with a history of schizophrenia who has been seen bi-monthly but is complaining of auditory hallucinations. (Psychiatry)

Office visit for a 62-year-old male, established patient, three years postoperative abdominal perineal resection, now with a rising carcinoembryonic antigen, weight loss, and pelvic pain. (Abdominal Surgery)  

Office visit for an 42-year-old male, established patient, nine months postoperative emergency vena cava shunt for varicealbleeding, now present with complaints of one episode of “dark” bowel movement, weight gain, tightness in abdomen, whites of eyes seem yellow and occasional drowsiness after eating hamburgers. (Abdominal Surgery)

Office visit for a 68-year-old male, established patient, with biopsy-proven rectal carcinoma, for evaluation and discussion of treatment options. (General Surgery)

Office visit for a 60-year-old, established patient, with diabetic nephropathy with increasing edema and dyspnea. (Endocrinology)       

Office visit with 30-year-old male, established patient for three-month history of fatigue, weight loss, intermittent fever, and presenting with diffuse adenopathy and splenomegaly. (Family Medicine)

Office visit for restaging of an established patient with new lymphadenopathy one year post-therapy for lymphoma. (Hematology/Oncology)

Office visit for evaluation of recent onset syncopal attacks in a 70-year-old female, established patient. (Internal Medicine)

Follow-up visit, 40-year-old mother of three, established patient, with acute rheumatoid arthritis, anatomical Stage 3, ARA function. (Rheumatology)

Follow-up office visit for a 65-year-old male, established patient, with a fever or recent onset while on outpatient antibiotic therapy for endocarditis. (Infectious Disease)

Office visit for a 75-year-old, established patient, with ALS (amyotrophic lateral sclerosis), who is not longer able to swallow. (Neurology)

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)  


Coding Ahead

99214 vs 99215

Hi everyone..

My provider asked me to run a report of E/M’s billed (99213-99215) over the past two months; mostly out of curiosity. Our 99215 visits are very low and he’s thinking that some of his level 4’s could have been level 5’s based on the complexity of his patients. I’ve read over the requirements in the CPT book and skimmed over the lengthy E/M guidelines from CMS, however, I’m wondering if any of you can provide me with a link to a document/table that I can show him to make it easier to reference to. I’ve been looking and haven’t had great luck. I may make my own but was hoping someone might have a good starting point for me. (I’m a fairly new biller) Main interest is comparison between 99214 vs 99215.

Also, when does time come into play? I know 99215 states 40min; need some guidance on whether or not that needs to be documented in the note if he bills based on MDM vs time.

I appreciate your time very much!!!

Medical Billing and Coding Forum

99215 ?? Feeling very frustrated

Provider coding office note below 99215. Patient has multi problems but none seem to be life threatening. Patient was not sent to ED for evaluation or sent out to any other facility for evaluation. This provider uses the 99215 quite frequently. He will code a 99215 for a Established patient to himself or the group for a Screening Colonoscopy and he’s the provider that will be preforming the Colonoscopy. His usage of 99215 makes me very uncomfortable and all coders at this facility have sent him notes regarding his usage of the 99215. We code for a Family Medicine Clinic Group.

Primary Care Provider: DR A
Accompanied by: Spouse
Visit Type: Acute Visit

Chief Complaint: f/u ED -continued rectal bleeding and belching

History of Present Illness:
Patient is a Years Old _ who presents for severe pain s/p umbilical hernia repair 2 days ago. Last night he/she began to have severe abdominal pain. He/She started having blood in his/her stool and went to the ER last night. He/She was sent home. WBC slightly elvated at 13.6 and Creatinine slightly increased at 1.47. He/She has a decreased appetite but has been able to tolerate liquids and solids without vomit. He/She has some severe abdominal pain and nauseated. He/She noticed incfeased urinary frequency which is clear/yellow color.
ER records reviewed which had a normal rectal exam.
Mild constipation from being on hydrocdone.

Problem List Changes:
Added new problem of Body mass index (BMI) 38.0-38.9, adult (ICD-V85.38) (ICD10-Z68.38) – Signed
Added new problem of Hematochezia (ICD-578.1) (ICD10-K92.1) – Signed
Added new problem of Other acute postprocedural pain (ICD-338.18) (ICD10-G89.18) – Signed
Added new problem of Abdominal pain, acute (ICD-789.00) (ICD10-R10.9) – Signed
Removed problem of Abdominal pain, acute (ICD-789.00) (ICD10-R10.9) – Signed
Added new problem of Abdominal pain, acute (ICD-789.00) (ICD10-R10.9) – Signed
Added new problem of Acute nontraumatic kidney injury (ICD-584.9) (ICD10-N17.9)
Assessed Abdominal pain, acute as new – Signed
Assessed Other acute postprocedural pain as deteriorated – Signed
Assessed Hematochezia as unchanged – Signed
Assessed Acute nontraumatic kidney injury as new
Assessed Abdominal pain, acute as unchanged

Medication List: (Reviewed and Updated)
IBUPROFEN 800 MG ORAL TABLET (IBUPROFEN) 1 po tid
MONTELUKAST SOD 10 MG TAB 10 TAB (MONTELUKAST SODIUM) TAKE ONE TABLET BY MOUTH DAILY
ZYRTEC ALLERGY 10 MG ORAL TABLET (CETIRIZINE HCL) 1 po qd
AVAPRO 300 MG ORAL TABLET (IRBESARTAN) 1 po qd
NORVASC 5 MG ORAL TABLET (AMLODIPINE BESYLATE) 1-2 po qd
ALDACTONE 25 MG ORAL TABLET (SPIRONOLACTONE) 1 po qd
CHLORTHALIDONE 25 MG ORAL TABLET (CHLORTHALIDONE) 1 po qd
TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR SOLUTION (TESTOSTERONE CYPIONATE) INJECT 2CC INTRAMUSCULARLY EVERY 2 WEEKS
YALE DISP NEEDLES 22G X 1-1/2" MISC (NEEDLE (DISP)) use as directed with Testosterone given IM q 2weeks
SYRINGE DISPOSABLE 3 ML (SYRINGE (DISPOSABLE)) use as directed with Testosterone IM q 2 weeks
BD DISP NEEDLES 18G X 1-1/2" (NEEDLE (DISP)) use as directed, use to draw up Testosterone give IM q 2weeks

Allergy List: (Reviewed and Updated)
No known allergies

Medical History: (Reviewed and Updated)
hypogonadism
traumatic brain injury
benign essential hypertension
onchmycosis
Sleep apnea
renal insuficency
allergic rhinitis

Surgical History: (Reviewed and Updated)
inguinal hernia
Nasla septum surgery

Social History: (Reviewed and Updated)
married with two children both boys.
Patient has never smoked.
Alcohol Use – yes
Drug Use – no
Regular Exercise – yes

Family History: (Reviewed and Updated)
aunt dementia
father type 2 diabetes
father hypertension
mother obese

Risk Factors:
Tobacco: (Reviewed and Updated)

Review of Systems:
COMPLAINS OF FEVER, CHILLS. All other systems reviewed and are negative

General: COMPLAINS OF FEVER, CHILLS.
Cardio: Denies chest pain, palpitations.
Respiratory: Denies SOB, cough.
GI: COMPLAINS OF ABDOMINAL PAIN, NAUSEA, CONSTIPATION, BLOOD IN STOOLS. Denies vomiting, diarrhea.

Vital Signs:
Weight: 274.2 lbs. (124.64 Kg.) Height: 71 in. (180.34 cm.) BMI: 38.38
Temperature: 97.6 deg F. (36.4 deg C.) Temperature Site: Temporal Pulse: 88 Pulse Rhythm: Regular
Blood Pressure #1: 138/88 mm Hg. Location: Rt Arm Position: sitting
Entered by:

Physical Exam:
General: Well developed, well groomed, in no acute distress.
Head: Normocephalic/atraumatic.
Eyes: PERRL, EOMI; conjunctiva and sclera clear.
Nose: No deformity/significant septal deviation; Normal mucosa.
Mouth: Mucus membranes moist; No erythema / exudates.
Neck: Supple; No thyromegaly or nodules.
Lungs: Clear to auscultation bilaterally.
Cardio: RRR; Normal S1, S2; Without murmurs, gallops, rub, or click.
Abdomen: severe periumbilical pain with guarding/ neg rebound
well healing periumbilical incision with some subcutaneous eccymosis

No masses
No hepatosplenomegaly
+BS
Extremity: No cyanosis or edema.
Skin: No rashes or atypical lesions.
Psych: Alert and oriented.

Assessment and Plan:

• ABDOMINAL PAIN, ACUTE (ICD-789.00) (ICD10-R10.9) Unchanged
concern for hematochezia s/p abdominal surgery. intra-op report reviewed which showed no acute complication.
recommend stat CT abd/pelvis (just approved with insurance). sent to radiology for labs and CT scan

• OTHER ACUTE POSTPROCEDURAL PAIN (ICD-338.18) (ICD10-G89.18) Deteriorated
pain worse than expected.

• HEMATOCHEZIA (ICD-578.1) (ICD10-K92.1) Unchanged
blood in stool is concerning.
pt had colonoscopy 2016 unremarkable except for a small sessile polyp

• ACUTE NONTRAUMATIC KIDNEY INJURY (ICD-584.9) (ICD10-N17.9) New
recheck bmp

Medication List Changes:
Removed medication of MOBIC 15 MG ORAL TABLET (MELOXICAM) 1 po qd; Route: ORAL – Signed

Removed medication of MELOXICAM 15 MG TABS (MELOXICAM) TAKE ONE TABLET BY MOUTH DAILY – Signed

Medical Billing and Coding Forum

99215 EGD consult

Provider wanting 99215 due to the decision for a diagnostic EGD. Does this document support the level? Thank you

Chief Complaint: EGD Consult

History of Present Illness:
Pt name removed is a age removed Years Old sex removed who presents today for diagnostic EGD evaluation.

Since July 2018 he/she has felt a lump in his/her throat that feels like "a chip stuck sideways". Onset without trauma or illness. The sensatation never goes away fully, and is made worse by swallowing liquids and pressing on his/her neck. Several times per week he/she has trouble getting fluids down because of the sensation, but is otherwise eating and drinking well. No personal hx of cancer, no fevers, chills weight loss. No hx or trauma or surgery to neck. No current tobacco/alcohol use. Recent thyroid workup including thryoid US negative. Pt endorses moderate to severe heartburn over the last 10 years, worse with lying flat. He/She has not tried antacid medication. He/she is also experiencing exercise-induced SOB with chronic non-productive cough over the last few months and having to use albuterol inhaler for asthma after years of not needing medication.

The patient was referred by: removed
Indication(s): globus with liquid>solid dysphagia

Previous EGD / Colonoscopy: None
Personal GI History: Heartburn for last 10 years, frequent childhood Strep throat infxns
Family History of Colon/GI Disease / Cancer: none

Anesthesia Concerns: None
ASA Class: II (asthma)
Bleeding Risks Noted: None

I have explained the prep and procedure in detail with the patient and answered all questions. The patient is willing for me to perform their EGD with or without biopsy using conscious sedation. They also agree to the risks as I have explained them which include, but are not limited to, excessive bleeding, pain, infection, adverse anesthesia reaction and/or colonic perforation.

Problem List Changes:
Added new problem of Globus sensation (ICD-306.4) (ICD10-F45.8)
Added new problem of GERD (ICD-530.81) (ICD10-K21.9)
Added new problem of Asthma (ICD-493.90) (ICD10-J45.909)
Changed problem from Body mass index (BMI) 32.0-32.9, adult (ICD-V85.32) (ICD10-Z68.32) to Body mass index (BMI) 33.0-33.9, adult (ICD-V85.32) (ICD10-Z68.33)
Assessed Globus sensation as new
Assessed Asthma as unchanged
Assessed GERD as unchanged

Medication List: (Reviewed and Updated)
OMEPRAZOLE 40 MG ORAL CAPSULE DELAYED RELEASE (OMEPRAZOLE) Take one by mouth daily
PROAIR HFA 108 (90 BASE) MCG/ACT INHALATION AEROSOL SOLUTION (ALBUTEROL SULFATE) two puffs q4 hours prn
NORGEST/E ES TRIPHASIC PK 28 (NORGESTIM-ETH ESTRAD TRIPHASIC) TAKE 1 TABLET DAILY (NEED APPOINTMENT)
IMITREX 50 MG ORAL TABLET (SUMATRIPTAN SUCCINATE) one po at onset of HA may repeat in 1 hrs if needed.

Allergy List: (Reviewed and Updated)
ERYTHROMYCIN (ERYTHROMYCIN OINT) (Critical)
SHELL FISH (Critical)
HIBICLENS (CHLORHEXIDINE GLUCONATE LIQD) (Critical)
CONTI CASTILE SOAP (SOAP & CLEANSERS) (Critical)
IODINE (Critical)

Medical History: (Reviewed and Updated)
chronic HA
acid reflux

Surgical History: (Reviewed and Updated)
none

Social History: (Reviewed and Updated)
Drug Use – no
HIV/High Risk – no
Regular Exercise – yes

Smoking History:
Patient is a former smoker.

Family History: (Reviewed and Updated)
Sister – Hypothryoidism
Aunt: BRCA positive

Sexual History: (Reviewed and Updated)
Last Menstrual Period: removed

Risk Factors:
Tobacco: (Reviewed and Updated)

Review of Systems:
All other systems reviewed and are negative

General: Denies fever, chills.
Cardio: Denies chest pain, palpitations.
Respiratory: Denies SOB, cough.
GI: COMPLAINS OF HEARTBURN, FREQUENT INDIGESTION, DIFFICULTY SWALLOWING. Denies abdominal pain, vomiting, diarrhea, nausea, constipation, blood in stools, dark stools.

Vital Signs:
Weight: 179.8 lbs. (81.73 Kg.) Height: 62 in. (157.48 cm.) BMI: 33.00
Temperature: 98.6 deg F. (37 deg C.) Temperature Site: Temporal
Respiration: 16 Pulse: 74 Pulse Rhythm: Regular
Blood Pressure #1: 122/72 mm Hg. Location: Lt Arm Position: sitting
Entered by: removed

Physical Exam:
General: Well developed, well groomed, in no acute distress.
Head: Normocephalic/atraumatic.
Mouth: Mucus membranes moist; Uvula midline; oropharynx mildly erythematous
Neck: Supple; No thyromegaly or nodules.
Lungs: Clear to auscultation bilaterally.
Cardio: RRR; Normal S1, S2; Without murmurs, gallops, rub, or click.
Psych: Alert and oriented. Judgement and insight intact.

Assessment and Plan:

• GLOBUS SENSATION (ICD-306.4) (ICD10-F45.8) New
Suspicious for GERD-induced globus in context of cough, worsening asthma, and regular heartburn. Relative lack of solid dysphagia reassuring. Ddx includes esophageal dysmotility, eosinophilic esophagitis, globus hystericus, esophageal cancer. Diagnostic EGD reasonable at this time. Will try trial of omeprazole 40mg as well. Pt consented today.

• ASTHMA (ICD-493.90) (ICD10-J45.909) Unchanged
Using albuterol inhaler several times weekly. Monitor for improvement with anti-acid therapy.

• GERD (ICD-530.81) (ICD10-K21.9) Unchanged
Pt has suffered with regular heartburn since the birth of her son. Could be causing globus sensation, cough, and worsening asthma. Trial of omeprazole 40mg po daily.

Medication List Changes:
Added new medication of OMEPRAZOLE 40 MG ORAL CAPSULE DELAYED RELEASE (OMEPRAZOLE) Take one by mouth daily; Route: ORAL Indications: DYSPHAGIA, OROPHARYNGEAL PHASE – Signed

Rx of OMEPRAZOLE 40 MG ORAL CAPSULE DELAYED RELEASE (OMEPRAZOLE) Take one by mouth daily; Route: ORAL #30[Capsule] x 3; provider and pharmacy removed

Orders:
Est. Level 5: Complete [CPT-99215][/COLOR]

Medical Billing and Coding Forum

Cpt 99215

My provider wants to charge 99215 for a ADD follow up, which was normal , and one new DX, L70.0 Acne, and DX L74.510 primary focal hyperhidrosis axilla. He did prescribe medication for new DX. However, I don’t think CPT 99215 applies. The new DX are not moderate to high severity problem, and no additional workup was done. My provider think is a 99215 because of new DX. Can he bill as 99215 because of new DX for this visit. Please help

Medical Billing and Coding Forum