2025 CPT code 99215
(Revised) Effective Date: N/A Revision Date: N/A Evaluation and Management - Office or Other Outpatient Services Evaluation and Management Feed
Office or other outpatient visit for an established patient; requires medically appropriate history and/or examination and high-level medical decision-making; when using total time, 40 minutes must be met or exceeded.
Modifiers may be used to indicate additional services provided during the visit (e.g., -25 for a significant, separately identifiable E/M service on the same day). Modifier -21 may be used if the total time spent exceeds 55 minutes.
Medical necessity is established based on the complexity of the patient's condition, the need for a comprehensive evaluation, the risk of complications, and the need for significant counseling and care coordination.Supporting clinical documentation is essential to demonstrate medical necessity to payers.
The physician performs a comprehensive assessment of the patient's condition, including history taking, physical examination,medical decision-making (diagnoses, treatment planning, and care coordination), and patient education and counseling. This may involve reviewing test results, consulting with other healthcare professionals, and coordinating care with other healthcare providers.
In simple words: This code is for a doctor's visit for a returning patient at their office or clinic.The visit is complex and takes at least 40 minutes, including time spent talking with the patient, reviewing medical records, ordering tests, and planning care.
This CPT code represents a comprehensive evaluation and management (E/M) service for an established patient in an office or other outpatient setting.The service necessitates a medically appropriate history and/or examination, and a high level of medical decision-making (MDM).When using total time to determine code selection, 40 minutes of time must be met or exceeded. This total time includes both face-to-face and non-face-to-face time on the date of the encounter.For services lasting 55 minutes or longer, code +99417 (prolonged services) should also be used; payer rules may vary.The level of history and examination does not impact code selection; however, all services must be appropriately documented.MDM elements include the number and complexity of problems, the amount and complexity of data reviewed and analyzed, and the risk of complications, morbidity, and mortality.
Example 1: A 65-year-old established patient presents with worsening congestive heart failure symptoms. The physician performs a detailed history, physical exam, reviews lab results, discusses treatment options (including medication adjustments and lifestyle changes), coordinates care with a cardiologist, and spends 45 minutes with the patient., An established patient with complex diabetes management needs requires a detailed review of their blood glucose monitoring, medication regimen, and complications. The physician educates the patient about dietary modifications, provides counseling on managing their condition, and coordinates care with an endocrinologist, taking a total of 50 minutes., A 78-year-old with multiple comorbidities (hypertension, chronic obstructive pulmonary disease, and dementia) has a follow-up visit, requiring significant time spent on reviewing medication side effects, communicating with family members, adjusting medication, and coordinating care with various specialists, with the total appointment lasting 60 minutes.
Detailed documentation is crucial, including a comprehensive history (chief complaint, present illness, past medical, family, and social history, review of systems), a thorough physical examination, and detailed notes on the medical decision-making process (problem complexity, data reviewed, risk of complications).Documentation should support the total time spent and justify the high level of MDM.
** Accurate documentation is paramount to avoid denials.Understanding the nuances of MDM and total time is crucial for appropriate code selection.Always verify payer-specific guidelines and reimbursement rates.
- RVU: RVUs vary based on geographic location and payer.Consult the appropriate fee schedule for specific values.
- Payment Status: Active
- Modifier TC rule: Not applicable.
- Fee Schedule: Historical fee schedules vary greatly by payer and location.Consult the appropriate payer's fee schedule for historical data.
- Specialties:This code is utilized across numerous specialties, including internal medicine, family medicine, cardiology, endocrinology, geriatrics, and others depending on the patient's condition.
- Place of Service:Office, Outpatient Hospital, Ambulatory Surgical Center