CPT® 99215: Evaluation and Management of an Established Patient, With High Level of Medical Decision Making, 40 Minutes - JF Part B
CPT® 99215: Evaluation and Management of an Established Patient, With High Level of Medical Decision Making, 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: Evaluation and management of an established patient, with high level of medical decision making, 40 minutes. 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 for CPT® 99215: Evaluation and management of an established patient, with high level of medical decision making, 40 minutes. The quarterly edit effectiveness results from April 1, 2024, to June 30, 2024, are as follows:
Top Denial Reasons
- The documentation submitted does not support the medical necessity of the level of service billed
- Failure to return records
- The documentation submitted did not include a valid signature and a response to attestation or signature log request was not received
Educational Resources
- How to Respond to ADR
- Documentation Guidelines for Medicare Services
- Updated Evaluation and Management Services Guide
- Medical Documentation Signature Requirements
Education
Providers report these codes for established patients being seen in the doctor's office, a multispecialty group clinic, or other outpatient environment. All require a medically appropriate history and/or examination excluding the most basic service represented by 99211 that describes an encounter that may not require the presence of a physician or other qualified health care professional. For the remainder of codes within this range, 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. Factors to be considered in MDM include the number and complexity of problems addressed during the encounter, amount and complexity of data requiring review and analysis, and the risk of complications and/or morbidity or mortality associated with patient management. Report 99212 for a visit that entails straightforward MDM. If time is used for code selection, a total time of 10 minutes must be met or exceeded on the day of the encounter. Report 99213 for a visit requiring a low level of MDM or meeting or exceeding 20 minutes of total time; 99214 for a moderate level of MDM or meeting or exceeding 30 minutes of total time; and 99215 for a high level of MDM or meeting or exceeding 40 minutes of total time. minutes of total time.
Failure To Return Records
The Internet-Only Manual (IOM) addresses timeframes for submission of records for pre-payment reviews in the Medicare Program Integrity Manual, Publication 100-08, Chapter 3, Section 3.2.3.2.
"When requesting documentation for prepayment review, the MAC and ZPIC shall notify providers that the requested documentation is to be submitted within 45 calendar days of the request. The reviewer should not grant extensions to providers who need more time to comply with the request. Reviewers shall deny claims for which the requested documentation was not received by day 46."
Incomplete And/Or Insufficient Documentation
When additional documentation has been requested to verify compliance with the CPT® code billed and the submitted documentation lacks evidence to support that, the claim will be denied as the documentation submitted was incomplete and/or insufficient. Refer to Internet Only Manual (IOM), Publication (Pub) 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8(C).
For additional educational resources, please visit our Education and Outreach department.
