July 29th, 2016
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.