Get the Answers on New Payment Rules for 99215

FCSO detailed a new claim reimbursement process in it's December 2012 medical billing newsletter for CPT Code 99215.  See below for details:


What: Prepayment Review of E/M Code 99215

The Medicare fiscal intermediary First Coast Service Options, Inc. (FCSO), will be initiating a pre-payment review of 100 percent of the E/M Service Code 99215.

Where: Florida

Who: Certain Provider Specialties

General practice


Osteopathic manipulative medicine

Pediatric medicine


When: Claims Submitted on or after January 18, 2013

Why: Conclusions of the OIG, CMS and FCSO

Upon examination of coding trends, the Office of the Inspector General (OIG) noted a 17% increase in the submission of E/M codes 99214 and 99215. As CMS agreed with their recommendations, efforts were initiated to encourage Medicare administrative contractors (MACs) to continue emphasizing the proper E/M scoring by providers billing these E/M services.

FCSO conducted it's own analysis that indicated a high risk of improper claim payment for certain specialties billing E/M code 99215 in Florida.

How: Receive Proper Claim Reimbursement for 99215

The CPT® manual defines code 99215 as follows:

Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components:

A comprehensive history

A comprehensive examination

Medical decision making of high complexity.

Usually the presenting problem(s) are of moderate to high severity. Typically, 40 minutes are spent face-to-face with the patient and/or family.

Billing Hint: Claims submitted with E/M code 99215 must be accompanied by documentation that justifies this level of medical necessity. By utilizing and E/M Scoresheet you can be assured of the accuracy of levels billed for your Evaluation and Management services.