What is a 99215 for E and M coding?

For a physician, nurse practitioner or physician assistant to be compensated for the services they provide to a patient they must correctly document the events that occurred in the room.  While most medical practitioners document the items, they feel are pertinent CMS has specific criteria that must be documented for the practitioner to bill for each level of service.

The E and M code 99215 is the specific code for an established patient Level 5 patient and is used less frequently than the 99214.  The reasoning behind the lower utilization is again due to the level of risk the patient presents with at the time of visit as well as the amount of history and exam needed.   The complaints needed to be a high-risk patient are those with a threat to life or limb among other emergent or threatening complaints. 

The items needed to code for this Level of service are made up of the 3 components of the progress note.  For a new patient all 3 components must be met.

1.) History-

  1. History of present illness- Duration, location, severity, modifying factors, associated symptoms, context, quality, and timing

  2. Past medical family and social history

  3.  Review of Systems – 14 recognized systems

  • Constitutional (e.g., fever, weight loss)

  • Eyes

  • Ears, Nose, Mouth, Throat

  • Cardiovascular

  • Respiratory

  • Gastrointestinal

  • Genitourinary

  • Musculoskeletal

  • Integumentary (skin and/or breast)

  • Neurological

  • Psychiatric

  • Endocrine

  • Hematologic/Lymphatic

  • Allergic/Immunologic 

2.) Exam- The physical exam component is comprised of  

  •  Constitutional (e.g., vital signs, general appearance)

  •  Eyes

  •  Ears, nose, mouth and throat 

  •  Cardiovascular 

  • Respiratory 

  • Gastrointestinal 

  • Genitourinary 

  • Musculoskeletal 

  •  Skin 

  • Neurologic

  • Psychiatric 

  • Hematologic/lymphatic/immunologic

3.) Medical Decision Making

  1. Diagnosis

  2. Treatment options- Medications, referrals, splints, etc..

  3.  Data review – Old records, labs, medical tests, imaging, etc…

  4. Level of Risk – Minimal, low, moderate and high

For a new patient in 99214, the following items must be met for each of the three components.

  • History – Four element of HPI, ten systems reviewed, and three PMFSH reviewed

  • Exam- eight systems examined

  • High-risk complaint and needs to have either: Four diagnoses, four treatment option or four data review.

Example: 99215

51 yo male here for a complaint of acute onset left arm and leg paralysis for 3 hours, he has not taken anything prior to arrival.  The patient states the symptoms are worse now than they were at onset and is associated with headache, neck pain left leg paralysis and left arm paralysis.

PMSFS- all reviewed

ROS – Neuro - positive Headache, left leg and arm paralysis 

            Musculoskeletal – positive for neck pain

             Eight other systems reviewed and negative (need each documented in the note)


Exam – General – well developed well-nourished 


Neuro–1/5 motor noted to left leg and left arm, left-sided facial droop noted on exam.


Six other systems examined (all eight systems must be documented n the note


Diagnosis – 1.) Left leg paralysis

                      2.) left arm paralysis

                      3.) Headache

                        4.) Neck pain


  • (HPI components)

  • (ROS systems)

  • (Systems examined ENT detailed)

As you can see from the above example what is needed is the exact same for an established 99215 as it is for a new patient 99205.

The other option for billing for Evaluation and management codes is the unit of time.  For a 99215 the practitioner must spend at least 40 minutes face to face with the patient and half of the time spent counseling the patient on treatment, lab results, and planning.  All these components should be documented.