"Billing too many 99214s and 99215s may draw the attention of auditors," says Kent J. Moore, manager of Health Care Financing and Delivery Systems for the American Academy of Family Physicians in Leawood, Kan. Good documentation is essential to justify your coding. Future Inpatient Is Typical 99215 Profile So when should an FP code a level-five established patient visit? "Our doctors often describe a 99215 as a hospital admission waiting to happen," Moore says.
Example: A patient presenting with any of the following conditions would clearly justify 99215, says William H. Ward, MD, IAFP, associate director of St. Francis Family Practice Residency Program in Beech Grove, Ind. Diagnoses include:
unstable angina (411.1, Intermediate coronary syndrome)
pulmonary embolism (415.1x, Pulmonary embolism and infarction)
severe exacerbation of chronic obstructive pulmonary disease (COPD) (491.21, Obstructive chronic bronchitis; with [acute] exacerbation) or asthma (493.x2, Asthma; with [acute] exacerbation)
pyelonephritis (such as 590.80, Pyelonephritis, unspecified) with comorbidities
transient ischemic attack (TIA) (435.9, Unspecified transient cerebral ischemia).
A patient with one of these conditions, may, however, turn into a hospital inpatient. Ward says that you could still report 99215 if the FP does not submit an initial hospital charge on the same day. Deteriorating Condition(s) May Require Level-5 Components A patient with four or more chronic illnesses may also warrant 99215. If one of the patient's conditions is deteriorating and requires additional evaluation - even on an outpatient basis - you could be in level-five territory, Ward says.
"Things like myotonic dystrophy type 2 (359.2) with chronic renal failure (585), coronary artery disease (such as 414.9, Chronic ischemic heart disease, unspecified), COPD, congestive heart failure (for instance 428.0, Congestive heart failure, unspecified) especially if associated with a complaint such as increased swelling (e.g., 729.81, Swelling of limb) or shortness of breath (786.05) could easily qualify," he says.
Note: Code 585 will require a fourth digit - 585.x - effective Oct. 1. Some other examples of single conditions that may justify 99215 include new onset of: shortness of breath
chest pain (786.5x)
syncopal episode (780.2, Syncope and collapse)
significant weight loss (783.21, Abnormal loss of weight) and fatigue (such as 780.79, Other malaise and fatigue).