The CPT code 99215 presents a complex and advanced patient management system. This code is used to manage the services provided to a specific set of patients. Understanding the whole range of dynamic services associated with this code is essential. You can only give adequate bing and documentation if you are putting this code to its right use.
Today, we are going to discuss the CPT code 99215 in complete detail. We are going to examine the essential aspects of the code and discuss the complete process of using this code for billing services.
Key Points for Using the CPT Code 99215
Some of the main key points about the usage of the CPT code 99215 are:
1. Usage
The CPT code 99215 is used for outpatient evaluation and management services for established patients only. This code represents the highest complexity for such visits in an outpatient setting or a primary care unit.
2. Specific Nature of Visit
The hospital can only use this code when an established patient having a disease visits the doctor for any reason. This reason might be a regular checkup or a consultation for any complexity of the disease. This code is specific for usage in high-risk diseases. Thus, these criteria have to be fulfilled during the visit before the hospital can use this specific code.
3. Time Requirement For Use
The code can only be used when the doctor spends a specific amount of time with the patient. Usually, this time is about 40 minutes, but can vary according to coding guidelines. Thus, if the hospital uses time-based coding, the doctor must spend at least 40 minutes with the patient during their face-to-face consultations.
4. History, Examination & Imaging
The doctor must take a comprehensive history from the patient to diagnose their condition. This includes recording the patient’s biodata, disease history, family history, and history of any past diseases or medications.
The doctor must also do the necessary examinations before reaching a differential diagnosis. The vital signs, systemic examinations, and the affected body systems should be checked before making any final diagnosis.
He should then request the necessary imaging procedures to make a conclusive diagnosis. These things are necessary for the coding process to go smoothly. Thus, the code will only work if the doctor has performed these procedures and has mentioned them in his patient reports.
5. Decision Making
Once the doctor has made the diagnosis, he should then discuss treatment options with the patient. The decision-making is also a complex process that relies on the expertise of the doctor. During this process, the doctor must take into account the chronic condition of the established patient. He must also advise the patient on the treatment options available. Once the patient is satisfied as to his disease and the possible treatment options, he can sign off the BIS and coding papers. Only then can the reimbursement process begin.
Usage Requirements
The CPT code 99215 can only be used in certain conditions. The hospital needs to keep in mind the following requirements when their coding department is preparing the final bills for the patient.
1. Established Patients
The CPT code 99215 can only be used for established patients who have already been diagnosed with a disease. These patients can have a chronic condition or some recent ongoing disease. These patients must have been seen by the same care provider or another with the same expertise within three years.
2. Documents Supporting the Case Complexity
Each established patient must have a complete document file supporting the complexity of the case. These can include a complete history, examinations, and other imaging papers. These documents should show that the patient is being treated for a complex condition that needs special attention. The documents should also report the decision-making process undertaken by the doctor.
3. Risk Assessment
The doctor must do a proper risk assessment of the condition of the patient. He must keep a thorough record of the risk of morbidities associated with the patient’s condition. The risk of mortality must be checked. A proper record of the risks associated with the treatment of the patient must also be kept on record.
Common Conditions that need 99215 Coding
Some of the most common conditions the doctor can experience that need CPT code 99215 include:
1. Chronic Conditions
Patients who present with chronic conditions and have multiple comorbidities should be listed under the code 99215. Care of these patients should fulfill the necessary requirements for 99215 code listing. A proper plan of coordinated treatment options should then be selected and properly documented for coding and billing.
2. Acute Exacerbations of Chronic Conditions
Patients with chronic conditions can also present to the doctor with acute exacerbations that need immediate attention. These patients come into the category of established patients and need treatment that also focuses on long-term relief. These patients should also be reported according to the 99215 coding system.
3. New Symptoms
Patients with chronic conditions can also present with new symptoms related to other systems. These symptoms need a thorough assessment using various examinations and imaging techniques. These new symptoms and their relevant diagnosis are also listed under the 99215 coding system.
Reimbursements
The 99215 coding system is associated with a higher degree of reimbursements and hefty sums. This is because the code covers complex symptoms, diagnosis, and treatment options that are very resource-consuming. To cover these bigger reimbursements, the coding system is also very complex and needs proper documentation. Thus, the hospital needs to perform specialized coding inputs and cross-checks if it is to get good reimbursement from the insurance company.
To ensure proper reimbursements, the following points need to be taken care of:
- Ensure proper, complete, and accurate documentation that contains the necessary details for the established patient.
- Use up-to-date coding guidelines and follow the newest coding changes to code the services.
- Make sure to use appropriate modifiers for any additional services provided to the patient to get adequate reimbursements.
- Submit clean claims with the necessary documents to ensure that you get your reimbursement on time.
Updates and Changes to the 99215 Coding System
The 99215 coding system is very dynamic like the rest of the coding and billing system. Many changes to the exact code specifications are made on a daily basis. Keeping abreast with these changes is very important for the hospital to ensure that it is complying with the newest guidelines. Thus, the hospital should try to keep in touch with authorities such as the American Medical Association (AMA) and the Centers for Medicare and Medicaid Services (CMS). These authorities are continuously updating the guides for using different codes and can help you use up-to-date codes.
Some other sources to stay up-to-date on the coding guidelines include medical coding journals such as the American Journal of Medical Coding, and professional coding organizations such as the American Academy of Professional Coders (AAPC). You can use any of these sources to get the newest guides on using appropriate codes for the services provided to the patients.
Conclusion
We have discussed some of the main points you should know about the CPT code 99215. The 99215 code is used for highly complex and established patients who have serious medical conditions. These patients can also present with acute exacerbations of their chronic conditions or some other new symptoms. All of these situations are managed under the 99215 coding system.
Since the services provided are complex and time-consuming, the code also needs proper documentation for the reimbursement process to go as smoothly as possible. It also means that the reimbursements given under this code are large and of hefty sums. Keep in mind all the necessary requirements when treating patients that come under the 99215 coding system. You can get big reimbursements if you follow the coding guidelines properly. Also read our comparison blog to know more about CPT Code 99216, 99215 and 99214.
FAQ - People Also Asks
The CPT code 99215 covers established patients that present to the hospital with complex conditions like chronic diseases or acute exacerbations of their chronic conditions. The 99215 code has a thorough coding and documentation process that needs attention to detail. Once the proper documentation has been done, the reimbursements provided to the hospital under this code are also very high.
The 99215 code needs proper documentation to get adequate reimbursement. This code can only be used in established patients who have chronic conditions and are being treated for these diseases by the healthcare provider. The hospital also needs proper documents for the code to work. A thorough history, examinations, and imaging studies should also be listed in the coding documents for the coding process to go through.
The 99215 code needs the healthcare provider to provide at least 40 minutes of one-to-one consultation to the patient. Although the exact minutes vary with the coding authority and implemented guidelines, the doctor must examine the condition of the patient for 40 minutes. Only then can the hospital list the service under the 99215 code and get adequate reimbursement for the service provided to the patient.