99205 and 99215 are among the most frequently flagged codes in health plan audits. Billing them without meeting documentation thresholds can result in claim denials and clawbacks.
Why these codes are scrutinized
Health plans have significantly increased their review of high-complexity E/M codes in recent years. This applies whether you're billing these codes as standalone or alongside a psychotherapy add-on. Documentation that doesn't clearly support the complexity level you're billing is a common audit trigger.
Billing 99205/99215 as a standalone code
To support 99205 or 99215, your note must meet one of two standards:
- Medical Decision Making (MDM): The note must reflect high-complexity medical decision making, per AMA guidelines.
- Total time: The note must document total time spent on the date of service, including pre- and post-visit work.
Billing 99205/99215 with a psychotherapy add-on
The bar is higher here. Time-based billing is no longer sufficient, and Medical Decision Making must be clearly documented in the note.
Documentation checklist
This checklist is designed to help you meet payer requirements and protect your practice from audit risk. The items are informed by AMA guidelines and the APA's Medical Decision Making guide.