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99215 and Medicare

  • 1.  99215 and Medicare

    Posted 02-17-2017 06:22
    In past 12-18 months I have had 3 requests for my records because of using 99215.   I suspect my use of 99214 and 99215 is making me an outlier.  My patients are scheduled every 30 miutes.  They tend to last approximately 40 minutes.    I dont  need to tell this group the complex nature of seniors problems and the savings to the system, etc.

    The "get out of jail free" card seems to be using a modifier "GA" and having an "ABN" on file.
    My question to group is how are others addressing this?   I realize that time is not the sole determination of a visit code but it is a very objective reality.)

    Are you just managing the clock and informing patient(s that their problems are complex and we need to schedule more time - We know this is not easy for many of our patients who rely on rides, etc.
    Are you having patients sign an ABN each visit?    Are you pausing visit at 25 minutes and asking patients to sign an ABN or schedule another visit? (Awkward).

    I have a few patients who have made it clear they do not want to be responsible so it is "easier" to end the visit at 25 minutes.

    I look forward to others suggestions.  Please dont just say that we should not accept medicare.   I understand and respect  that philosophy.  However, I like my patients and the relationships and dont want to change dramatically at this stage of my career.


    Michael S. MD

  • 2.  RE: 99215 and Medicare

    Posted 02-18-2017 05:21
    3 requests in how long? 
    I personally don't use the 99215 very frequently. When I do use it I make sure the clinical documentation and the time is documented also. My new patient visit is 60min. Subsequent visit 30min. Most of the time I bill 99214 for Chronic care visit. I don't have patients sign ABN. I would just continue to  make sure that the documentation is consistent with the 99215. I end up seeing my medicare patients 4-5 times / year sometimes that includes AWV. Greetings to everyone! 

    Edgar Cruz
    Cruz Medical Services
    Clermont FL

  • 3.  RE: 99215 and Medicare

    Posted 02-18-2017 15:07

     I went and looked up GA modifer and got upset
    I would not use an abn  for a 9915
    that is for things like cosmetic stuff that is not or unlikely to be covered Otherwise i submit my 99215 and document the hell out of it I have a macro that prints out "50% of the visit time was counseling or care coordination"
     I find 3 or 4 dx     I think you cannot use the 50%   based on time rule with  new visits
    I admit I worry about 99215s so prob sometimes I undercode

    Being an iMP I have long heard that upstate mid NY state medicare carreir  will not pay for some things Myria Emeny used to say this She was outside of Albany
     Appeal? Call  your sneotr or the CMS regional office?
      The story of Earl Carstenson in CO is well docuemtned about 12 yrs ago on the AAFP  list serv He was tortured by UNited  which was  way over 50% of his panel, for  using too many 99214s    he  would see people for 1 thing an d have them leave becasue he was  so tortured by United  He took them to task and got AAFP on his side but he suffered alot

         Jean Antonucci MD
         115 Mt Blue Circle
         Farmington ME 04938
    ph 207 778 3313   fax 207 778 3544

  • 4.  RE: 99215 and Medicare

    Posted 02-19-2017 21:06
    Thanks Jean and Edgar.

    Curiously, on the three visits I was reviewed, I did not use the GA modifier.   

    I think I will be more diligent about having the ABN signed and continue using the GA modifier.   My reading and understanding of GA and ABN seem to support how I use them.

    On the first two claims I submitted records for over the past 2 years or so, I have not had my coding overturned or down coded.   I just submitted records for the third visit.    

  • 5.  RE: 99215 and Medicare

    Posted 02-20-2017 05:03
    ABN's are to be used for something that might not be covered.  More like a 99354 (prolonged visit).  A 99215 should be covered.   Additinally you have to tell the patient what their out of pocket cost would be .  Be careful with this.

    I bill almost exclusively 99214.  All my visits are scheduled 30 minutes and sometimes go longer.  The time part of E & M coding is for counseling.  So if you are going to say you spent 20 minutes of your 40 minute visit counseling you need to document that like JEan said (> 50% spent on counseling.  You need to have the time documented.  I have a patient in and patient out time stamp in my note.  And you need to document what you timed.  I rarely code a 99215 as it usually requires a comprehensive physical which I rarely do.  And, many health plans other than Medicare, have blended codes and don't really pay more for a 99215 anyway.  More often, if a patient really tied me up for a long time, I will through the 99354 code on and with that, you could get an ABN but I think Medicare covers it.  

    ABN's are not even for paring callouses and skin tags and SK removals, not medically necessary, Td boosters, not covered.  I have never had a patient sign an ABN.  

    Kathy Saradarian

  • 6.  RE: 99215 and Medicare

    Posted 02-20-2017 13:33
    Thanks Kathy.  Good discussion.

    I will need to double check, but I believe the CMS letter specifically asks if I have an ABN on file.  And if I do, I can bill the patient for the 99215.   If, after submitting notes,  the reviewer feels documentation does not support the 99215, and no ABN on file, I cannot bill the patient. 

    pg 5 of this link is a nice table.:

    The way i read it, 99214 (25 min F2F) plus 99354 (requires at least 30 minutes of additional time beyond the E/M code) requires I spend at least 55 min. F2F with pt.. 

    So if I spend "just" 45 minutes total time with patient, I dont meet criteria for using 99214 + 99354.  If I bill 99215, I risk having note reviewed, possibly not paid, risk of audit, etc.

    Neither option is a pleasant one.   That takes me back to my original post.  Is ABN a "Get out of jail free" card?

    Michael S. MD

  • 7.  RE: 99215 and Medicare

    Posted 02-21-2017 05:51
    ABNs mean you can bill the patient for the visit if Medicare doesn't cover the visit.  I wouldn't call it a "Get out of Jail Free" card.   The problem is just because you spend 50 minutes doesn't mean you need to spend 50 minutes.  If you are doing the counseling for all that time, then by all means bill for it.  Just make sure you are documenting clearly you time and how much was spent on counseling and what counseling.  Then you have to decide if it's worth it to you.  Because you will always be appealing the denial and sending in a copy of your notes.  

    If you just bill the patient, then just drop out of Medicare and be FFS.  Make sure you tell the patient what their fee will be.  But expect to get a bunch of pissed off patients who either, walk out after 30 minutes or stop coming because they can't keep paying out of pocket for something Medicare should be covering.  

    You could bill a 99213 with the 99354 code, but again, many insurances make the patient responsible, not sure about Medicare, I don't do it often.  

    This has always been a tough issue.   I pretty much only bill 99215 for very medically complex issues in a patient who is acutely ill and we are keeping out of the hospital.   Never with a chronic disease routine appointment.  Maybe for a patient with multiple chronic disease issues who also saved up a couple of new acute problems.  

    Kathleen Saradarian, MD
    Branchville, NJ

  • 8.  RE: 99215 and Medicare

    Posted 02-21-2017 06:23
    Kathy always helps I am so glad we have her    I am also sure that her JE an was deliberate:)


         Jean Antonucci MD
         115 Mt Blue Circle
         Farmington ME 04938
    ph 207 778 3313   fax 207 778 3544