I had a wheezer in the office, can I bil a 99215?

July 27th, 2015 - Codapedia Editor
Categories:   Coding   Evaluation & Management (E/M)   Primary Care|Family Care  
0 Votes - Sign in to vote or comment.

At a coding session at a recent Pri-Med conference a Pediatrician asked this question:

"I had wheezer in the office, and he was in the office a long time.  I examined him, we did pulxe oximetry measurements, which we never get paid for both before and after a nebulizer treatment.  I was in and out seeing him a number of times.  Can I bill a 99215 for that?"

This is a common scenario for Pediatricians and Family Physicians.  A patient with an asthma exacerbation comes into the office.  The clinician examines the patient, orders a nebulizer treatment, and watches over the patient.  The nursing staff is with the patient for a long time, and the clinician in and out.  Does it meet the criteria for a 99215?

Probably not based on time.  In order to use time as the determining factor, the physician or PA or NP must personally be with the patient for 40 minutes face-to-face time, and more than 50% of the visit must be in counseling.  (See the Codapedia article on using time to select a code.)  This visit probably will not meet those requirements.

This means, in order to bill a 99215, the clinician must meet the requirements in 2 out of 3 of the key components, of history, exam and medical decision making.

  • The required history is: 4 HPI elements, at least ten systems in the review of systems, and two of past medical, family or social history.
  • The exam must be either an eight organ system exam (1995 guidelines) or 18 elements from 9 systems  (1997 guidelines)
  • The MDM must be high: for example, a new problem with work up planned and a severe exacerbation of a chronic illness. 

This visit will probably not audit with high MDM, so the clinician must document the history and exam components listed above, and it must be medically necessary to do so.

Using resources in the office (staff time, an exam room, equipment and supplies) does not translate into a higher level of service.


Questions, comments?

If you have questions or comments about this article please contact us.  Comments that provide additional related information may be added here by our Editors.

Latest articles:  (any category)

HIPAA Penalty Changes
January 11th, 2021 - Wyn Staheli, Director of Research
On January 5, 2021, H.R. 7898 was signed into law by President Trump. This new law modifies the HITECH Act such that when an organization experiences a breach, fines and/or penalties may be reduced if (for at least a year) they have instituted “recognized security practices” as defined within the law.
CDT and CPT - The Same but Different!
December 8th, 2020 - Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
Reporting a CPT code for an evaluation of a patient is based on time and if the patient is a new or established patient. Evaluation and Management codes are different than other codes, it is important to understand how they are used, prior to 2021 they were based on a ...
How to Search Find-A-Code for Medicare Policies and Guidelines — LCDs, NCDs and Articles —
November 18th, 2020 - Raquel Shumway
Help for Searching Find-A-Code when searching for Medicare Policies and Guidelines — LCDs, NCDs and/or Articles.
Cross-A-Code Instructions in Find-A-Code
November 18th, 2020 - Raquel Shumway
Cross-A-Codeis a toll found in Find-A-Code which helps you to locate codes in other code sets that help you when submitting a claim.
COVID Vaccine Codes Announced
November 11th, 2020 - Wyn Staheli, Director of Research
On November 10, 2020, the American Medical Association (AMA) announced the addition of two new codes which will be used for the new COVID-19 vaccines along with 4 new administration codes to be used when reporting the administration of these vaccines.
Are You Aware of the 2021 Star Rating System Updates?
November 5th, 2020 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
Each year the Centers for Medicare & Medicaid Services (CMS) publishes the Star Ratings System Updates for Medicare Advantage (Part C) and Medicare Prescription (Part D). This rating system was developed to help beneficiaries identify and select the health plans that best meet their needs, specifically addressing main issues:  Quality of ...
Special Needs Plans Help Beneficiaries and Risk Adjustment Reporting
October 22nd, 2020 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
It is no secret that Medicare and Medicaid are steadily moving towards their goal of value-based health care. Medicare Part C (Medicare Advantage) identifies and rewards payers, and subsequently their providers, for increasing the efficiency and quality of care they provide to Medicare...

Home About Contact Terms Privacy

innoviHealth® - 62 E 300 North, Spanish Fork, UT 84660 - Phone 801-770-4203 (9-5 Mountain)

Copyright © 2000-2021 innoviHealth Systems®, Inc. - CPT® copyright American Medical Association