In past issues we have discussed in depth (and hopefully to your financial benefit and in a compliance-friendly manner) the use of the basic evaluation and management (E/M) office visit codes, 99213 and 99214. Now it is time to tackle the least-used office code, 99215. Unlike many of our internal medicine counterparts, pediatricians often code only a handful of these codes in a year’s time, even though most of us more commonly perform a service that would qualify for the billing of this code than we may realize.

The documentation guidelines published by the Health Care Financing Administration (HCFA) in 1995 and 1997 contain the documentation criteria that should be placed in the record to ensure it is complete and would stand up to audit. You may be audited if your number of higher-level codes is high compared with peers (profiling), but the good news is you will pass if...

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