Overcoming Your “Level 5” Fears

June 19, 2023

I have found that there are two types of physicians:

  1. Those who shy away from using the 99205/99215 codes—”the dreaded Level 5”—for fear of triggering audits; and
  2. Those who use these codes as often as possible.

WHICH ONE ARE YOU?

In my years of experience, more physicians “down-code” to 99204/99214, even if their dictation clearly states and warrants Level 5. When I ask them, “Why?” I usually receive one of these three responses:

  • They have been cautioned about using Level 5 too often; or
  • They were audited for lack of documented information; or
  • They have never used Level 5 for fear of being audited.

Here’s the good news:
These codes are NOT as scary as people tend to think, and if used correctly the “audit police” will not show up at your door. In fact, these codes should be used more often (with the proper documentation or time, of course; as I have written in previous issues of Coffee & Coding, if it is not documented it was not done).

So, let’s clear up the myths and take the fear out of the dreaded Level 5 codes (99205/99215).

First, definitions:
The 99205/99215 codes are for office or other outpatient visits to evaluate and manage an established or new patient. The visit requires a medically appropriate history and/or examination and a high level of medical decision-making. At least two of three key components must be present in the medical record: a comprehensive history, a comprehensive examination, and medical decision-making of high complexity. The visit must last between 40-54 minutes for established patients and 60-74 minutes for new patients.
Now let’s turn to what you will need for diagnoses to properly qualify for Level 5. I have listed a few examples (not an all-inclusive list) below:

I have listed a few examples (not an all-inclusive list) below:
  • I50.9 – Heart failure, unspecified
  • I50.23 – Acute on chronic systolic heart failure
  • I50.33 – Acute on chronic diastolic heart failure
  • I50.43 – Acute on chronic combined systolic and diastolic heart failure
  • E11.65 – Type 2 diabetes mellitus with hyperglycemia
  • E11.69 – Type 2 diabetes mellitus with other specified complication
  • Cancer – Progression during cancer treatment; Proctitis during radiation treatment for prostate cancer1
  • Hypertension – Hypertension or high cholesterol that required medication changes
  • Diabetes – Diabetic ketoacidosis3
  • Heart disease – Acute on chronic systolic heart failure; Acute on chronic diastolic heart failure; Acute on chronic combined systolic and diastolic heart failure2
  • Asthma – Severe asthma exacerbation

Feeling a little less dread? Hopefully, you will feel even better after you read next week’s Coffee & Coding, where we will cover how to handle Complexity of Data and Risk requirements for Level 5.fears. 

Download PDF

More Coffee & Coding

The Problem with Independent Historians

The Problem with Independent Historians April 8, 2024 In most cases, we know who independent historians are: mothers, fathers, guardians, grandparents, or adult children. But we still see many instances when the term is incorrectly applied in the documentation—mostly,...

Making Complexity of Problems a Little Less Complex

Making Complexity of Problems a Little Less Complex April 1, 2024 We see a lot of questions (and confusion) over what constitutes an “acute illness with systemic symptoms.” In fact, according to the American Academy of Pediatrics, “Of the three elements that make up...

Making the Right Choice Between Level 3 and Level 4: Part Two

Making the Right Choice Between Level 3 and Level 4: Part Two March 25, 2024 In last week’s Coffee & Coding, we provided a refresher on key points to remember about coding appropriately for Level 3. This week let’s do the same for Level 4. Level 4 can be a little...

Level 3 or Level 4: Getting It Right

Level 3 or Level 4: Getting It Right March 18, 2024 Guidelines notwithstanding, deciding whether to apply Level 3 or Level 4 to a patient encounter isn’t always easy. In fact, we see a lot of inconsistency and confusion on this point. While many clinicians accurately...

Ending Confusion over Modifier 25

Ending Confusion over Modifier 25 March 11, 2024 It’s a big week here in Boston (my hometown). Sunday, of course, is St. Patrick’s Day. Here in Boston, we also remember March 17 as Evacuation Day—marking the anniversary of the British army leaving the city in 1776....

MDM Level 5: A Quick Refresher on a Complex Subject

MDM Level 5: A Quick Refresher on a Complex Subject March 4, 2024 We continue to see that, across all medical specialties, physicians are still nervous about billing for Level 5 office visits. I consistently find that many (if not most) providers code for Level 4 even...

HIPAA Compliance: Make sure you know ALL the rules

HIPAA Compliance: Make sure you know ALL the rules February 26, 2024 The Health Insurance Portability and Accountability Act (HIPAA) of 1996 is a federal law restricting access to individuals' private medical information. That much, I’m sure, our readers already knew....

Making sense of the new coding-by-time rules for 2024

Making sense of the new coding-by-time rules for 2024 February 19, 2024 We all know that the new year brings changes (some years, more than others). As it turns out, no sooner had we gotten clinicians on track with how much time belongs to the E/M CPT code set than...

How do you code a broken heart?

How do you code a broken heart? Plus: We answer your questions about toxicity monitoring. February 12, 2024 First things first: While remembering to apply the proper codes and include sufficient documentation, providers and coders must not lose sight of one essential...

Documentation Tips and Tricks: How to Avoid Common Mistakes

Documentation Tips and Tricks: How to Avoid Common Mistakes February 5, 2024 Every day we see coding mistakes that affect the accuracy of E/M coding levels. Some of them can be costly. So, in this issue of Coffee & Coding, we’ll look more closely at some of these...

Toxic diagnosis coding: What you may be missing

Toxic diagnosis coding: What you may be missing January 29, 2024 Three quick questions: When did you last look in that little section towards the back of your ICD-10 coding book called the Drug Table? How often have you coded an adverse reaction to a bug bite as...

Why and how to use the new SDOH codes

Why and how to use the new SDOH codes January 22, 2024 Social Determinants of Health (SDOH) have become increasingly important in determining the needs of patients and directing them to the help they need. For 2024, we have both a new diagnosis code as well as a new...

The long-awaited G2211 code: What you need to know

The long-awaited G2211 code: What you need to know January 15, 2024 There’s an important new code for 2024, and it pays (literally*) for you to know how and when to use it. Up to this point, E/M coding has failed to take into account the resources, time, and cost...

What’s changed in telehealth services?

What’s changed in telehealth services? January 8, 2024 The other day, another coder asked me whether post-operative services could be performed under telehealth. It occurred to me that there are probably more coders with the same questions. So, we’re devoting this...

Don’t Toss Those Old Code Books Just Yet

Don’t Toss Those Old Code Books Just Yet January 2, 2024 Welcome to 2024! After all the preparations, training, and education, are you ready to implement what we learned over the past four months about coding changes? Here are a couple of the most critical secrets to...

Subscribe to Our Weekly Coffee & Coding Newsletter