What is it, who can bill for it and who will reimburse it?
These two Current Procedural Terminology Codes belong to a certain “family” of billing codes that includes 99211-99215. They are also a part of the Healthcare Common Procedure Coding System. You can expect to see CPT Codes 99214 and 99215 used for office visits for medical and mental health conditions. These appointments must be for already established patients only.
CPT Codes 99214 and 99215 can be viewed as extremely similar. Therefore, it is understandable that some healthcare professionals might find differentiating between their billing choices rather confusing. These two codes may be connected in many different ways, but they do require some completely different components for billing. Therefore, paired with the fact that one code is reimbursable for a higher amount, it is important for clinicians to ensure that they are receiving the highest monetary amount possible for their reimbursements for billing. However, it is even of greater importance to ensure that these reimbursements are processed successfully.
Many clinicians find that they bill with CPT Code 99215 very frequently, but some worry that it will be more difficult for reimbursement. However, once you know the rules and regulations and stick to them, you will find that billing with either code is simple. Let’s take a look at both CPT Codes 99214 and 99215 to learn more.
What exactly are CPT Codes 99214 and 99215?
CPT Code 99214 is a code that is issued for the second highest level of care for a patient’s office visit. CPT Code 99214 can only be used for an established patient’s office visit, and it is a level four code. It can be used to bill for an in-office visit or in an outpatient setting. Reimbursement for 99214 is more than 99212 or 99213. This is exactly why CPT Code 99214 is used the most when billing for this type of appointment. Reimbursement for this code and those within its set of codes really became popular back with the Affordable Care Act’s long-awaited inclusion of mental healthcare in 2006.
CPT Code 99215 can be used for a high level of complexity appointment, and it is only used in 5% of visits. CPT Code 99215 is a level five code that should only be used for an patient with an established history. Billing with this code could produce up to 25% more in reimbursements that CPT Code 9214. However, attempting to bill with this code when it does not apply could welcome in audits. But, there is absolutely no reason not to bill with CPT Code 99215 when the situations warrants it. This is why understanding the regulations is very important in so many ways.
Who can bill with CPT Codes 99214 and 99215?
All sorts of medical professionals have the ability to bill with CPT Codes 99214 and 96215. The really wonderful news in this scenario is that clinicians practicing as other than mental health providers or therapists still have great success in billing with both of these codes.. Behavioral health assessments can used as extremely important tools in all sorts of healthcare settings, including primary care, cardiology and more.
Let’s look at a simple example of a cardiologist using CPT Code 99214. A patient may have a routine appointment for a heart healthy checkup. During the office visit, the patient may begin to describe the feelings of anxiety that he/she feels when pressure on the chest is experienced. Sometimes this may turn what began as momentary heart spasm into a full-blown anxiety attack. Upon hearing this account, the cardiologist may then decide to set a referral in motion for the patient to see a mental health professional to address the anxiety, as that it could have a direct impact on the patient’s health. Standardized assessment tools for anxiety (e.g. PHQ-9) may also be used to try to gather more information and analyze the severity of these emotions.
An easy-to-understand example of a physician using CPT Code 99215 the scenario of a young woman who is experiencing some health problems after a surgery on her thyroid. This patient is also experiencing chronic back pain for the last three years due to a slip-and-fall accident, and she is being treated with muscle relaxants. There are also feelings of depression associated with the pain and the after effects of the surgery. Behavioral assessment tools can be used to monitor the depression, as well as to utilize for deciding a course of action. The physician may set up a referral for therapy or a support group.
What procedures are there for billing CPT Codes 99214 and 99215?
For billing with CPT Code 99214, there must be two out of three components present for the correct billing of Code 99214. These necessary factors are:
- A detailed interval history
- A detailed examination
- Moderate complexity medical decision making
A mix of two out of three of these components is required to bill for CPT Code 99214 must be utilized in face-to-face time of at least 25 minutes with the patient. The reasons for the visit are typically of a moderate to high complexity.
The conditions that must be present for CPT Code 99215 billing are also outlined in a simple manner. While the factors differ between codes, there must be two out of three of the following components:
- A comprehensive history
- A detailed examination
- High complexity medical decision making
There must be a mix of these three components, along with 40 minutes of face-to-face time with the patient. The problems discussed during the appointment are typically considered to be of a higher severity.
The detailed or comprehensive history of the patient can be gained through thorough examination of the patient’s charts and records. However, this information can also be gained through mental health assessment tools. This can also be most helpful in understanding if any health problems could be further intensified by mental health conditions.
Remember that detailed exams are not always included in decision making. This could simply be a referral to see a specialist (e.g. a psychologist or a psychiatrist), a new prescription or a change in diagnosis.
How often can testing be billed with CPT Codes 99214 and 99215?
When the patient in questions require moderate to high levels of care during the appointment, billing for this care is very important. CPT Codes 99214 and 99215 may be billed according to time spent with the patient at each scheduled appointment. Not only will clinicians be able to bill at higher levels, but they can utilize behavioral assessment tools to discover and measure mental health conditions that could be present.
How much are reimbursements for screenings billed using CPT Codes 99214 and 99215?
When billing with CPT Codes 99214 and 992, face-to-face time spent with the patient during the visit is the basis for the reimbursement. Behavioral assessment instruments are also included as one of the tools to be used during the appointment. To get an idea of the monetary difference between the two codes, a major national healthcare insurer’s policies list CPT Code 99214 as reimbursable for up to $107.20 for each patient. With the same insurer, CPT Code 99215 is reimbursable for up to $144.80 for each patient. This represents a difference of over $37 for each appointment with each patient. This is but one of the reasons that it is so important to understand the differences between billing CPT Codes 99214 and 99215.
Where can I find standardized screening instruments to use with CPT Codes 99214 or 99215 for behavioral assessments?
Mentegram has a library full of online tools, such as the PHQ-9. These tools can be utilized as sliding scales or questionnaires to assess mental health conditions. This can increase the factors of billing with higher complexity codes (e.g. billing CPT Code 99215 instead of 99214). But the benefits don’t stop there! Clinicians using these tools can also reduce and even replace paperwork, as well as save time with patient intake and monitor their patients, even in between appointments.
What are the most important things to remember about differentiating between CPT Codes 99214 and 99215?
- Always note the difference between the components that are required for each code to bill that particular complexity.
- Ensure that medical necessity is present during the moderate to high level care.
- Check your information to be certain that the documentation supports the level of care that is being billed.
So, are you ready to start billing with CPT Codes 99214 and 99215, as well as with other codes today?
Find more detailed information on how to bill with CPT Codes, while increasing your practice’s revenue. Read our additional articles on CPT Code 96127 and CPT Code 96103, plus comparisons between CPT Codes 99213 and 99214:
DISCLAIMER: Please keep in mind that Mentegram is a healthcare technology company, and do not consider content on our website as legal advice. It is your responsibility to decide to act on this content, relinquishing Mentegram of all claims. The information that we share is based on what has been effective for our customers and the best practices as published by authoritative sources.
For specifics regarding your individual practice and specific cases, please consult the particular insurance companies or your office’s billing consultant for additional information.