Prepayment of evaluation and management code 99215

First Coast Service Options Inc. (First Coast) recently conducted data analysis due to the high comprehensive error rate testing (CERT) error rate for evaluation and management service pertaining Current Procedural Terminology (CPT®) code 99215 (Office/outpatient visit established). CERT reviews indicated the errors were based on insufficient documentation, medically unnecessary services and services incorrectly coded.

Documentation requirements

The American Medical Association (AMA) CPT® manual defines code 99215 as follows:
Office or other outpatient visit for the evaluation and management (E/M) of an established patient, which requires at least two of these three key components:

• A comprehensive history
• A comprehensive examination
• Medical decision making of high complexity.

Usually the presenting problem(s) are of moderate to high severity. Typically, 40 minutes are spent face-to-face with the patient and/or family.

Furthermore, claims submitted with E/M code 99215 must be supported by documentation indicating the medical necessity for this level of service.