99215

A common issue we run into these days, is patients with multiple problems, as well as some 'new problems' that they have been 'saving up. An example would be a 55 year old gentleman with diabetes, high blood pressure and elevated cholesterol. All are fairly stable and eval/management consistent with a 99214 visit. BUT he has also been feeling tired the last few weeks, and has been having vague upper abdominal pain for about six months. In addition to his routine testing/counseling/medication refills, his visit now requires additional history, exam, blood work, imaging and care coordination (e.g. referral to his cardiologist).

It is surprising how common this type of scenario has become with patients requesting additional evaluation at their visit (more bang for their copay). I realize this isn't very specific, but could these types of visits justify a 99215 - not because of the acuity of illness, but from the complexity of history/physical/coordination of care etc. Thanks.