CPT CODE 99215: Established Patient Office or Other Outpatient Services, Level 5
In this quick reference guide to CPT code 99215, we answer frequently asked questions from our community of chiropractors. Follow us for other articles in our ongoing series, courtesy of ChiroTouch, the cloud-based EHR designed specifically for chiropractors.
About CPT Code 99215: Established Patient Office or Other Outpatient Services, Level 5
Evaluation and Management (E/M) services play a crucial role in chiropractic care, allowing practitioners to assess and manage patient health effectively. CPT code 99215 specifically pertains to a comprehensive E/M service, typically 40 minutes or longer.
Chiropractors can benefit from understanding the nuances of CPT code 99215 to ensure accurate and efficient coding for their E/M services. Here’s what chiropractors need to know about using CPT code 99215.
Category or Type of Service
CPT code 99215 falls under the Evaluation and Management (E/M) code category. It represents a comprehensive E/M service, indicating a thorough examination and management of a patient’s health status, typically 40 minutes or longer. As an E/M code, it is reported separately from other procedures or services, allowing chiropractors to bill for their assessment independently.
CPT code 99215 is billed as a single unit for each encounter. When using this code, the duration and complexity of the service are important considerations.
Billing intervals should accurately reflect the time involved in the service provided. However, the primary deciding factor when choosing between one code and another in this series is the complexity of the encounter; time is a secondary consideration.
When Should Chiropractors Use This Code?
Chiropractors should use CPT code 99213 when they perform a detailed examination and management of a patient’s health of moderate complexity. This code is appropriate for encounters that involve a thorough assessment, decision-making, and coordination of care.
Common scenarios where this code would be appropriate include encounters with patients who have complex health issues or cases where you or your staff spend a significant amount of time reviewing medical records and coordinating care with other healthcare providers.
When choosing among levels in the 99211-99215 series, prioritize medical decision-making (MDM) over length of visit as the primary factor in determining the correct code level. Time is a secondary but still important consideration.
|New patient office visit, level 1
|New patient office visit, level 2
|New patient office visit, level 3
|Established patient office visit, level 4
|Established patient office visit, level 5
|50 or more minutes
When Should Chiropractors Not Use This Code?
Chiropractors should not use CPT code 99215 for routine visits that don’t involve a comprehensive evaluation and management service, or encounters where the complexity of the patient’s health status does not warrant detailed examination and management.
A good rule of thumb is to look at how much time and how many other people were involved in the casework. The more thorough you had to be, the more justified a 99215 usage is.
Which Modifiers Can Be Used With This Code?
Modifiers that are used with CPT code 99215 include:
- Modifier 25: This modifier indicates that a significant, separately identifiable E/M service was performed on the same day as another procedure.
- Modifier 57: Decision for surgery during an E/M service. This modifier is not commonly used by chiropractors but may be key if you are involved in surgical decision-making.
- Modifier 59: Distinct procedural service.
- Modifier 95: Synchronous telemedicine service. This modifier notes the encounter was via an online platform.
What Are the Billing Guidelines and Documentation Requirements Specific to This Code?
Your documentation must support the comprehensive nature of the E/M service provided.
When using code 99215, include a detailed history, examination, and medical decision-making process.
Ask yourself the following:
- Is all the documentation clear on what was done and the complexity of the services provided?
- Is all documentation legible, with handwriting transcribed if needed?
- Can you easily determine the date these services were offered?
If you can answer “yes” to these questions, then you’re likely to be fully conforming to the correct guidelines.
Are There Specific Billing Guidelines That Apply to this CPT Code When It’s Used in Combination With Other Services?
According to the National Correct Coding Initiative (NCCI), CPT code 99215 can be billed in combination with other services if the services are medically necessary and separately identifiable from the other services provided. Chiropractors should ensure that documentation clearly distinguishes the E/M service from any concurrent procedures.
What Are Common Mistakes Made Specific to CPT Code 99215?
The most common mistakes with this code include:
- Overuse of the code. Applying 99215 for routine visits or encounters that don’t involve a comprehensive evaluation and management service, or utilizing it for follow-up appointments lacking significant changes in patient status.
- Insufficient documentation. Noncompliance with documentation guidelines necessary to support the use of 99215, including failing to provide:
- A comprehensive history
- A thorough examination
- Documentation of complexity of medical decision-making
- Incorrect billing interval. Usually due to billing 99215 more than once per encounter, or multiple days or weeks for a single evaluation.
- Inappropriate use of modifiers. Using modifiers incorrectly, such as applying modifier 25 when the E/M service isn’t separate and distinct from other procedures.
- Non-compliance with NCCI edits. Neglecting to check NCCI edits or overlooking restrictions on billing 99215 with certain other services often leads to potential billing errors or denials. NCCI edits are specific and should be referenced for each individual case. Medicare’s NCCI tool is a good resource for double-checking.
- Failure to consider time. While time is not the only factor for determining E/M levels, consistently short visit times can raise red flags during audits.
What Are Potential Audit Triggers Specific to CPT Code 99215 and How Can I Avoid them?
Potential audit triggers specific to CPT code 99215 include:
- High utilization. Avoid billing 99215 significantly more often than other E/M codes, or significantly more than your peers.
- Using this code for less complex evaluations. Be sure the service provided was a truly comprehensive evaluation as opposed to a routine visit, and be sure to document complexity appropriately.
- Lack of documentation. Incomplete or insufficient documentation to support the level of service billed is a common audit trigger. Ensure thorough documentation of history, exam, medical decision-making, and time and effort spent.
- Pattern of billing. Check to make sure you’re not consistently billing 99215 on the same day as other services, or for certain patient types or conditions. Use modifiers appropriately to clarify distinct services. Ensure medical necessity for all services billed.
- Upcoding: Don’t bill 99215 when a lower-level E/M code would be more appropriate based on documentation. Choose the code that accurately reflects the level of service provided.
Simplify Billing with ChiroTouch
Cloud-based ChiroTouch provides numerous features that help to streamline chiropractic billing and coding.
These features include:
- Efficient billing workflows. ChiroTouch makes billing tasks simple and less prone to human error.
- Easy-to-use dashboard. ChiroTouch makes it easy for all staff members to find the information they need — all in one place.
- Processing automation. With automatic insurance processing, ChiroTouch cuts down on time spent on manual tasks while minimizing errors.
- Automatic posting. Payments go to patient accounts, avoiding problems like double billing.
- Flexible payment options. ChiroTouch offers multiple payment options, providing extra convenience to patients.
- Clearinghouse integration. ChiroTouch puts everything in one place to speed up claims.
- Data organization. Track different case types separately, and better manage billing data.
ChiroTouch also helps with compliance and reducing audit risk with:
- Easy access to information. With ChiroTouch, patient data is easy to find and provide.
- Automated billing and insurance payments. Reduce time spent on invoices while increasing accuracy and keeping payment records near to hand.
- Simplified Explanation of Benefits (EOBs). ChiroTouch syncs EOBs directly into your system, making them easier to access.
- Educational resources. ChiroTouch helps you stay informed with up-to-date training resources.
Try ChiroTouch for Yourself
To learn more about what the coding and billing features of ChiroTouch can do for your practice, get a one-on-one demonstration and answers to all your questions. Book a demo today!