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How to use CPT code 99215

Code 99215 represents an existing patient appointment that’s at least 40 minutes in duration.

The 99215 code is an E/M code used by prescribing providers. For other E/M codes, visit this overview.

CPT code 99215 description

Code 99215 represents an existing patient appointment that’s at least 40 minutes in duration. It’s a prescriber code, which means it’s most commonly used by psychiatrists or nurse practitioners. 

This is is how the American Medical Association defines 99215 in the official CPT codebook:

CPT code 99215: Existing patient office visit, minimum 40 minutes

Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded.

99215 vs 99205: Existing patient vs. new patient

If you’re treating a new patient, you should use 99205 instead. A new patient is someone you have not seen in the last three years.

It’s important to use the code that most accurately reflects the time you spent with the patient to treat their condition, and ensure that documentation for the session supports the chosen code. 

CPT code 99215 time frame

CPT code 99215 is a returning patient appointment of at least 40 minutes. Other time frames for a new patient should be coded with [99212] (at least 10 minutes), [99213] (at least 20 minutes), or [99214] (at least 30 minutes).

CPT code 99215 documentation

Documentation for 99215 is essentially the same as other E/M codes, but geared toward an existing patient.

  • Problem-focused history: Document relevant information about the patient’s presenting complaint, medical history, and any other important factors.
  • Problem-focused examination: Perform and document an evaluation that’s appropriate for the patient’s presenting complaint.
  • High complexity medical decision making: Make a judgment about the patient’s diagnosis, create a care plan, and prescribe appropriate treatments or interventions. You can find a full table of levels and elements of MDM here.
  • If you are billing based on time, include start/stop timers.


In the example note below, the following factors are present:

  • Number and complexity of problems addressed: 1 chronic illness with severe exacerbation (Bipolar disorder, current episode mixed, severe, without psychotic features)
  • Data reviewed/analyzed: None
  • Risk: High, decision regarding hospitalization


The encounter meets the criteria for a 99215 code based on the high level of medical decision-making required for managing the severe exacerbation of bipolar disorder, including consideration of hospitalization. 

The treatment plan involves high-risk decision-making regarding acute intervention and crisis management to address the immediate safety and stabilization needs of the patient.

Patient Name: Whitney Johnson

Date of Service: 10/24/2024

Patient DOB: 09/12/1990

Appointment Time: 10:00 am – 10:50 am

Place of Service: Patient was located at their home at 123 Main St Anywhere US 12345 

Provider was located at their office: 456 Storybook Ln Hollywood CA 96852 

This session was provided via a HIPAA compliant interactive audio/video platform. The patient consented to this telemedicine encounter.

Subjective

Chief Complaint: Urgent follow-up for a 34-year-old female with severe exacerbation of bipolar disorder symptoms, including anxiety and suicidal ideation with a plan to overdose if symptoms worsen.

HPI:

Ms. Johnson reports significant mood instability, with manic episodes characterized by impulsivity and racing thoughts, and depressive episodes marked by hopelessness and suicidal ideation. She also describes heightened anxiety, worsening during periods of alcohol cravings or social exposure. Although she has not relapsed, she feels overwhelmed by her anxiety, fearing it could trigger drinking again.

Objective

Allergies: No known drug allergies.

Substance Use Assessment: History of alcohol dependence with associated anxiety (F10.280). Currently not drinking but reports intense cravings during stressful episodes.

Exam:

Vital signs within normal limits. Patient exhibits psychomotor agitation during manic episodes and psychomotor retardation during depressive episodes. Mood observed as highly labile, with periods of elevated affect and tearfulness.

MSE:

  • Appearance: Appropriately dressed, appears stated age.
  • Behavior: Psychomotor agitation and retardation alternating with mood phases.
  • Speech: Rapid during mania, slowed during depressive states.
  • Mood: Labile throughout the session.
  • Affect: Shifts between elevated and tearful.
  • Thought Process: Disorganized during mania, logical during depressive phases.
  • Thought Content: Expresses hopelessness with fleeting suicidal ideation.
  • Cognition: Alert and oriented x3.
  • Insight/Judgment: Impaired during manic states; better insight during depressive phases.

Assessment

Dx: F31.63 Bipolar disorder, current episode mixed, severe, without psychotic features

F10.280 Alcohol dependence with alcohol-induced anxiety disorder

Plan

1. Consideration for Inpatient Admission: Due to the severity of Ms. Johnson’s bipolar exacerbation and the anxiety related to alcohol dependence, inpatient psychiatric hospitalization was considered. After collaborative discussion, hospitalization will be deferred, contingent upon the patient’s agreement to follow a structured safety plan.

2. Pharmacological Intervention:  

  • Initiate divalproex sodium (Depakote) 250 mg twice daily for mood stabilization and acute symptom management.
  • Add quetiapine (Seroquel) 50 mg at bedtime to control manic symptoms and improve sleep.

3. Safety Plan and Patient Agreement:

  • The patient agrees to:
  • Daily check-ins with their substance use counselor to monitor cravings and anxiety. Immediate contact with the provider or the on-call psychiatric team if suicidal thoughts worsen.
  • Avoiding alcohol and high-risk social situations, with support from an accountability partner.
  • Follow-up appointment in one week for re-evaluation.

4. Relapse Prevention and Coordination of Care:

  • Maintain collaboration with the patient’s substance use counselor to support sobriety and prevent relapse.
  • Monitor for mood changes, substance cravings, and adherence to the safety plan at follow-up.

Electronically signed by:

[Provider Name, Credentials, Date]

_____________________________________________________________________________________________

Rationale information is not required in your note; it is provided for educational purposes only.  

Rationale and How the CPT Code Was Selected (based on 2/3 elements):

Number and Complexity of Problems Addressed: 2 chronic illnesses Bipolar disorder with severe exacerbation and Alcohol dependence with alcohol-induced anxiety disorder.

Data Reviewed/Analyzed: None.

Risk of Complications and/or Morbidity: High risk, consideration of inpatient admission

Rationale: This encounter qualifies for a 99215 code due to the high level of medical decision-making involved, including managing a severe exacerbation of bipolar disorder and coordinating inpatient hospitalization for stabilization and crisis management.

CPT Code Selected: 99215

CPT code 99215 reimbursement rates

Reimbursement rates for sessions billed with 99215 will vary depending on factors like the specific payer contract, your geographic location, and type of therapy license. Headway providers can check the portal for rates with each insurance provider.

Find out your rates with Headway

This document is intended for educational purposes only. It is designed to facilitate compliance with payer requirements and applicable law, but please note that the applicable laws and requirements vary from payer to payer and state to state. Please check with your legal counsel or state licensing board for specific requirements.

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