Question: Some doctors in other practices will code Medicare patients with a level 5, 99215, when they do a complete history and physical. They justify it by saying they’ve done what it takes to qualify for this level of service. What is the current thinking on this practice?
Answer: If you do a level 5, you code a level 5. Just make sure you know what is required and that it’s all documented. A “complete history and physical” may or may not count.
Specifically, a 99215 requires two of these three components:
- A comprehensive exam: A general multi-system exam or comprehensive exam of a single organ system.
- A comprehensive history: Chief complaint, extended history of present illness, review of systems related to present illness plus review of additional systems, a complete past, family, and social history.
- Medical decision making of high complexity: Highly complex medical decision making might include, per CPT examples, a patient with four or more stable chronic illnesses. That sounds like a lot of Medicare patients. Treatment options might include medications requiring intensive monitoring. Again, typical of many Medicare patients. You might consider having a coding expert come do a prospective audit of your documentation and claims to see if you could accurately bill the level 5 or not.