What CPT (Current Procedural Terminology) code is used for an extensive history and medication intake?

CPT Codes for Extensive History Medication Intake

For extensive history medication intake, use CPT code 99215 for established patients or 99205 for new patients, as these codes account for comprehensive history-taking including detailed medication review requiring high complexity medical decision making. 1

Understanding E/M Coding for Medication History

When conducting an extensive medication history intake, the appropriate coding depends on several factors:

For Office/Outpatient Visits:

• New Patients: Code 99205 is appropriate when the visit involves:

  • Comprehensive history (including extensive medication review)
  • Comprehensive examination
  • High complexity medical decision making
  • Typically requires 60-74 minutes of total time 1

• Established Patients: Code 99215 is appropriate when the visit involves:

  • Comprehensive history (including extensive medication review)
  • Comprehensive examination
  • High complexity medical decision making
  • Typically requires 40-54 minutes of total time 1

Key Documentation Requirements

To support these high-level E/M codes for extensive medication history:

1. Document the complexity of the medication review, including:

   • Number and types of medications reviewed
   • Potential interactions identified
   • Medication reconciliation performed
   • Time spent specifically on medication history

2. Medical decision making should reflect the complexity of managing multiple medications, which may include:

   • Risk assessment of medication interactions
   • Evaluation of medication effectiveness
   • Assessment of adherence issues
   • Adjustments to medication regimens

Alternative Coding Options

If the service is specifically for medication management rather than a complete E/M service:

• Medication Management: Consider code 90863 for pharmacologic management, including prescription and review of medication effects 2

• Care Plan Oversight: For complex medication management over time, codes 99374-99380 may be appropriate, which include telephone calls and medication management over a 30-day period 2

Pitfalls to Avoid

1. Undercoding: Extensive medication history intake represents significant cognitive work and time investment. Using lower-level codes may not appropriately reflect the service provided.

2. Insufficient documentation: Ensure documentation clearly demonstrates the complexity and time involved in the extensive medication history to support the higher-level codes.

3. Modifier usage: When medication history is part of a preventive visit but represents significant additional work, use modifier 25 to indicate a separately identifiable service 1

Best Practices

• Document the time spent specifically on medication history if using time-based coding
• Clearly indicate the complexity of the medication regimen being reviewed
• Note any specific interventions resulting from the medication history
• Include the medical necessity for the extensive medication review

By selecting the appropriate E/M code that reflects the comprehensive nature of extensive medication history intake, you ensure proper reimbursement while accurately representing the clinical work performed.