CPR’s “Coding Corner” focuses on coding, compliance and documentation issues relating specifically to physician billing. This month’s tip comes from G. John Verhovshek, managing editor for AAPC, a training and credentialing association for the business side of health care.  

Claims for level 5 established outpatient visits (CPT® 99215) have been targeted by Centers for Medicare & Medicaid Services (CMS) Recovery Audit Contractors (RACs), as well as private and government payers, following a 2012 Office of Inspector General (OIG) report that claimed providers have reported higher level E/M codes for all types of E/M services in recent years. This shouldn’t discourage providers from reporting 99215, when appropriate, but you should keep the following points in mind. 

Medical necessity trumps all. The number one requirement driving any medical service is always medical necessity. Medicare’s Claims Processing Manual, Chapter 12, section 30.6.1.A, stipulates:

Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT® code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed.

In other words, the level of service billed must be commensurate with a patient’s presenting problem or chief complaint. If the reason for the patient encounter is not documented, you cannot report the service. If the patient presents without either a complaint or signs/symptoms (e.g., follow-up, annual exam, etc.), you cannot report a problem-focused E/M service, but should instead turn to preventive medicine codes.

HPI demonstrates medical necessity. Medical necessity is demonstrated based on information captured in the history of present illness (HPI). Documentation quality matters more than quantity. The information should be relevant to the presenting problem(s), and it should seek to answer the questions each HPI element asks, as follows:

• Location: e.g., back pain, nasal congestion


• Quality: e.g., sharp or shooting pain, dry cough


• Severity: e.g., extremely nauseated, moderate pain


• Duration: e.g., onset two weeks ago


• Timing: e.g., worse in the mornings, occurs constantly


• Context: e.g., dizzy upon standing, worse after exercise


• Associated signs/symptoms: e.g., chief complaint of nausea accompanied by associated symptoms of vomiting and diarrhea


• Modifying factors: e.g., no relief from over-the-counter meds, improves with rest

Note that only the performing provider may document HPI. Copying the nurse’s notes or patient responses in a questionnaire does not count.

Diagnosis alone doesn’t justify a high-level E/M. Follow-up visits with critically (or terminally) ill patients won’t necessarily call for a high-level E/M service. For example, when a patient is in the middle of chemotherapy, and no adverse reactions are reported or no new complaints are noted, the visit would not merit a high level just because there is a cancer diagnosis.

MDM is the single best indicator of E/M service level. In the everyday struggle to assign E/M codes, medical decision-making (MDM) is usually the best indicator of the E/M service level. When two of three components (history, exam or MDM) are necessary to support the level of service (as is the case with 99215), CPT® does not require that MDM must be one of those elements. Generally speaking, however, the history and exam should approximate the level of MDM, because MDM influences the extent of history and exam that are required. For example, the use of documentation templates can make it too easy to document more detail in the history and exam than is necessary, which can lead to upcoding.

Reserve 99215 for the sickest patients. The “sickest” patient does not mean the patient is heading to the emergency room or to the hospital for admission (although such patients would surely qualify). The “sickest” patient, in this context, can be the patient with multiple stable chronic conditions that require ongoing monitoring to assure that the patient is compliant with the treatment plan, and that the treatment plan is effecting the desired outcome. Identifying non-compliance or ineffective treatment may present a higher risk to the “sickest” patient.

CMS specifically allows for providing the status of chronic illnesses as an alternative method to describe the history of the presenting problem. To count as HPI, the name of the illness must be stated, along with the status of the illness and a description of the treatment plan. Be sure to document your decision-making processes by listing any possible concerns regarding the status of multiple chronic conditions. This will assist in identifying the “sickest” patients, and provide clarity in supporting medical necessity for 99215.