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Physician wants to charge 99215

Nancy Posted Sat 23rd of February, 2019 12:30:20 PM
Is it true that pretty much any new patient visit where i counsel them about prostate cancer/RALP or kidney cancer/robotic partial nx, can be billed as a level 5 bc of decision making and complexity? Patient was seen for one diagnosis code prostate cancer and physician documented time, physical examine did not include prostate exam. I spent a total of 40 minutes in the care of this patient, of which greater than 50% of time was spent in face-to-face counseling and coordination of care. To me the time spent should be 60 for level 5.
SuperCoder Answered Mon 25th of February, 2019 02:49:27 AM

Hi Nancy,


For a NEW patient, 60 minutes should be spent face to face with the patient to match the requirements of CPT code 99205. In this case, 40 minutes were spent in the care of the patient, appropriate CPT code would be 99203 (30 minutes face to face with the patient). Even CPT code 99204 would require 45 minutes face to face with the provider. Mere counselling about prostate cancer, kidney cancer or robotic surgery would not lead to high MDM.


Per Documentation: If the documentation can support comprehensive history, comprehensive examination and medical decision making of high complexity, you can bill 99205.

  • Comprehensive history: Expended HPI with 10 system review of systems (ROS) along with Past, Medical, Family, Surgical and Social history well documented in the records.
  • Comprehensive Examination: 8 organ system examination
  • Medical Decision Making: High level in 2/3 of Number of diagnoses/Management options, amount and/or complexity of data received and Table of risk.

All the above-mentioned parameters once attained would lead to high level MDM (Medical decision making).


Hope provided information would be helpful!



Nancy Posted Mon 25th of February, 2019 07:01:11 AM
Thank you
SuperCoder Answered Mon 25th of February, 2019 23:40:30 PM

Happy to Help!

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