What documentation supports a 99215 for complex patients?

99215 requires high complexity MDM. Document: 1+ chronic illness with severe exacerbation OR acute/chronic condition posing threat to life/function, extensive data (external records + independent interpretation + discussion with external provider), AND high-risk decision (drug therapy requiring intensive monitoring, decision for hospitalization, or escalation of care). Address each element clearly.

How many problems should be documented for complex patient visits?

The number of problems matters less than their severity and management complexity. One severe problem with life-threatening exacerbation supports 99215, while multiple stable chronic conditions might only support 99214. Document each problem's current status (stable, worsening, exacerbation) and the specific management decisions for each.

How do I document medical decision making for multiple chronic conditions?

For each condition, document: current status (controlled, uncontrolled, exacerbation), recent relevant data reviewed, clinical reasoning for assessment, and specific management plan. Use the problem-oriented format. For MDM: 2+ stable chronic conditions = moderate (99214), chronic illness with mild exacerbation = moderate, chronic illness with severe exacerbation = high (99215).

When should time-based billing be used for complex visits?

Use time-based billing when total time spent exceeds the threshold for the MDM-based code. Time includes: pre-visit preparation, face-to-face time, and post-visit documentation/coordination. Thresholds: 99214 = 30-39 min, 99215 = 40-54 min, prolonged services (99417) starts at 55 min for established patients. Document total time and breakdown.

How do I handle care coordination documentation for complex patients?

Document: specialists involved in care, recent communication with specialists (counts toward data for MDM), coordination activities performed, care plan updates made, and medication reconciliation. If you spend significant time on care coordination, consider whether CCM billing is appropriate in addition to face-to-face visits.

Complex Patient Visit Template - Multiple Problems

Internal Medicine — Complex Patient Visit Template

Internal Medicine Internal Medicine Updated: 11/7/2025

The Complex Patient Visit Template is designed for internists and primary care providers managing patients with multiple active medical problems requiring comprehensive evaluation and coordination. This template supports appropriate billing for complex visits (CPT 99214-99215) and documents multiple problems, extensive history, comprehensive examination, and complex medical decision-making. The template includes sections for problem list with all active conditions, detailed history for each significant problem, comprehensive review of systems, complete physical examination, review of multiple test results, assessment of each problem with clinical reasoning, treatment plan addressing each problem, care coordination needs, and follow-up planning. This template ensures thorough documentation of complex patients, supports appropriate billing for complexity, facilitates care coordination, and improves patient outcomes through systematic management. Ideal for internal medicine practices, primary care practices managing complex patients, and practices participating in value-based care programs.

Visit Information

Visit type: Complex patient visit / Multiple problem management
Active problems: [Number of active problems]

Problem List

1) [Problem 1]
2) [Problem 2]
3) [Problem 3]
[Continue for all active problems]

History of Present Illness

For each significant problem:

[Problem 1]: [Current status, symptoms, changes]
[Problem 2]: [Current status, symptoms, changes]
[Problem 3]: [As applicable]

Review of Systems

[Comprehensive ROS covering all systems]

Physical Examination

Vital signs: BP, HR, RR, Temp, SpO2, BMI
General: [Appearance]
HEENT: [Complete exam]
Cardiovascular: [Complete exam]
Respiratory: [Complete exam]
Abdomen: [Complete exam]
Extremities: [As indicated]
Neurological: [As indicated]
Other: [As indicated]

Laboratory/Imaging Review

[Review of multiple test results relevant to problems]

Assessment

For each problem:
1) [Problem 1] — Status: [Assessment with clinical reasoning]
2) [Problem 2] — Status: [Assessment]
3) [Problem 3] — Status: [As applicable]
[Continue for all problems]

Plan

For each problem:
1) [Problem 1]:

Medications: [Continue / Adjust / Add]
Diagnostics: [Labs, imaging]
Referrals: [If needed]
Monitoring: [Specific monitoring]

2) [Problem 2]: [As applicable]
3) [Problem 3]: [As applicable]

Care Coordination

Specialist involvement: [List]
Care coordination needs: [Actions needed]
Medication reconciliation: [If complex]

Follow-up

Return in [timeframe] for complex patient follow-up / Problem-specific follow-ups: [Schedule]

Patient Instructions

Multiple problems reviewed. Treatment plan for each problem discussed. Patient verbalized understanding.