CPT® 99215: Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded

In order to fulfill its contractual obligation with CMS, Noridian Healthcare Solutions (Noridian), your Medicare Contractor, performs pre-payment reviews in accordance with CMS direction. CMS is required by the Social Security Act to ensure that payment is made only for those medical services that are reasonable and necessary. Medical review assesses submitted documentation to validate provider compliance with Medicare payment rules and regulations, including coverage, coding and billing guidelines.

This is to update providers of the claim review findings for CPT® 99215 : Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded. The results of this focused review are not a reflection on providers' competence as a health care professional, or the quality of care provided to patients. Specifically, the results are based on the documentation requested by Medicare and/or your facility's compliance with the required documentation.

The Jurisdiction F Part B Medical Review Department is conducting a Targeted Probe and Educate (TPE) review of CPT® 99215 : Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded. The quarterly edit effectiveness results from April 1, 2025, through June 30, 2025, are as follows:

Top Denial Reasons

  • Denial Reason 1 - Failure to return records
  • Denial Reason 2 - The documentation submitted was incomplete and/or insufficient
  • Denial Reason 3 - The documentation submitted supported the key elements and/or reasonable necessity of a lower level of service

Educational Resources

Education

These codes are reported for established patients seen in the doctor's office, a multispecialty group clinic, or other outpatient environment. Patients must have received prior professional services from the provider or another provider in the same specialty group practice in the previous three years. All visits require a medically appropriate history and/or examination. Proper Current Procedure Terminology (CPT®) code selection is based on the level of medical decision making (MDM) or total time personally spent by the physician and/or other qualified health care professional(s) on the date of the encounter. It is the responsibility of providers to be familiar with the descriptive terms and identify the most appropriate and comprehensive CPT® or Healthcare Common Procedure Coding System (HCPCS) codes for reporting medical procedures and services. The complete, descriptive documentation of all services rendered is absolutely necessary in order for a claim to be properly evaluated. These CPT® code selections include:

  • CPT® 99212: Straightforward MDM; requires 10 minutes
  • CPT® 99213: Low level MDM; requires 20 minutes
  • CPT® 99214: Moderate MDM; requires 30 minutes
  • CPT® 99215: High MDM; requires 40 minutes

Factors to consider in MDM include:

  • Number and complexity of problems addressed during the encounter
  • Amount and complexity of data requiring review and analysis
  • Risk of complications and/or morbidity or mortality associated with patient management

To be considered for payment, documentation submitted must meet the Benefit Category requirements described in Title XVIII of the Act, support service is reasonable and necessary as defined under §1862(a) (1) of the Act, and support service is provided to the beneficiary as billed. Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of an E/M visit code. It would not be medically necessary or appropriate to bill a higher level of E/M service when a lower level of service is warranted. Documentation should include the history and exam performed in addition to the medical decision making performed. When time is the determinant for code selection, total time should be documented. Medical necessity must be clearly documented and support the level of service billed. Refer to Title XVIII Social Security Act Section 1862(a)(1)(A), Medicare Claims Processing Manual chapter 12 section 30.6.1 (B), and the Medicare Program Integrity Manual chapter 3 section 3.6.2.5, AMA's 2021 and 2023 changes to office, outpatient, and other E/M visits and the CPT® manual.

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