Office Outpatient Services, 99201-99215
These codes are used when a privileged provider collects a medically related history, performs an exam, and makes a medical decision in a DoD healthcare facility on a patient who is not admitted as an inpatient to a healthcare facility.
CPT code is 99215, the Comprehensive assessment. This code requires at least two out of these three components
o A comprehensive history
o A detailed examination
o Medical decision making of high complexity
When billing code 99215, a good tip is to note that this assessment is broad in scope or content demonstrating extensive understanding of the patient’s condition. Most likely, the presenting problems are of moderate to high severity. Typically 40 minutes are spent face-to-face with the patient and/or family.
Shared Medical Appointments (SMA)
SMAs are visits when multiple patients meet with the provider and a behaviorist at the same encounter. A list of chief complaints is compiled. All patients are present for those parts of the examination not requiring privacy. The provider examines each patient individually and addresses the patient’s issues. Immediately after completing the encounter with each patient the provider documents the encounter while the behaviorist furnishes general education/counseling. When the provider completes the documentation, the provider starts the next patient’s exam. This continues until all the patients are evaluated and treated. SMAs usually take 60-90 minutes to complete. SMAs will be coded based on documentation. Only one encounter per patient will be completed. The appropriate E&M code will be assigned according to the documentation (i.e., prevention/office visit). The modifier “TT” indicating individualized services with multiple patients present will be used when this modifier is available for use in the ADM
Use of Highest Levels of E/M Codes
To bill the highest levels of visit codes, the services furnished must meet the definition of the code (e.g., to bill a Level 5 new patient visit, the history must meet the CPT’s definition of a comprehensive history).
The comprehensive history must include a review of all the systems and a complete past (medical and surgical) family and social history obtained at that visit. In the case of an established patient, it is acceptable for a physician to review the existing record and update it to reflect only changes in the patient’s medical, family and social history from the last encounter, but the physician must review the entire history for it to be considered a comprehensive history.
The comprehensive examination may be a complete single-system exam such as cardiac, respiratory, psychiatric or a complete multi-system examination
