99215 visits take 3 checks before you bill
Medicare's 2026 national physician rate for a 99215 is $192.39. Check the problem, the risk, and the time, and write each one in the note.
Head of Growth and Operations, JotPsych
You saw a patient today in a severe manic episode of bipolar disorder. You weighed a hospital admission and chose outpatient care. Your visit ran 45 minutes, and you're about to bill a 99214.
As a 99215, the visit pays $56.78 more than a 99214 at Medicare's 2026 national physician rates. The national nurse practitioner rate for a 99215 is $163.53.
- 1The problem: a severe exacerbation, or a threat to life or bodily function
- 2The risk: a hospitalization decision, or drug therapy that needs intensive monitoring for toxicity
- 3The time: 40 minutes or more of your time on the date
The checks come from the American Medical Association table and the 99215 descriptor. A note that shows the problem and the risk, or the time, supports a 99215.
- Check the problem. Your note's level of medical decision making (MDM) comes from three elements in the American Medical Association (AMA) table: the problem, the data, and the risk. High-level problems include a chronic illness "with severe exacerbation, progression, or side effects of treatment." Name the severity in your note, in plain words.
- Check the risk. High risk includes a "Decision regarding hospitalization" and "Drug therapy requiring intensive monitoring for toxicity." The AMA's guidelines add that "a decision about hospitalization includes consideration of alternative levels of care." Two high elements, the problem and the risk, are enough for a 99215. Write down the decision you weighed and why.
- Check the time. Time is the other way to reach a 99215, and your total time on the date has to reach 40 minutes. Medicare's billing guide asks for "a start and stop time or the total time" in your note.
How commercial averages compare with Medicare
PayerPrice's national averages for a 99215 run from $165.55 at Aetna to $198.27 at Cigna, and the averages don't name a clinician type.
PayerPrice's national averages put Cigna above Medicare's 2026 national physician rate for a 99215. Blue Cross / Anthem, UnitedHealthcare, and Aetna average 86.0% to 90.3% of the physician rate.
Run the three checks on each of your crisis visits before the claim goes out, and bill a 99215 when your note supports one.
JotAudit in JotPsych checks your 99215 against the note before you sign and shows the code the note supports.
Book 15 minutes- Centers for Medicare & Medicaid Services, PFS Relative Value Files: 2026 national physician rates and short descriptors (such as "Office o/p est mod 30 min") from the October 2026 release (RVU26D), file PPRRVU2026_Oct_nonQPP, conversion factor 33.4009.
- Legal Information Institute, Cornell Law School, 42 U.S.C. 1395l(a)(1)(N) and (O): Medicare pays 80 percent of the lesser of the actual charge and the fee schedule amount for a physician's service, and 80 percent of "the lesser of the actual charge or 85 percent of the fee schedule amount" for a nurse practitioner's, read October 2, 2026.
- American Medical Association, CPT evaluation and management office visit revisions, Table 1: Levels of Medical Decision Making, effective January 1, 2021.
- American Medical Association, CPT Evaluation and Management (E/M) Code and Guideline Changes, effective January 1, 2023: the risk element.
- Centers for Medicare & Medicaid Services, Medicare Learning Network, Evaluation and Management Services (MLN006764), May 2026.
- PayerPrice, CPT 99215 fee schedule by payer, national averages by payer, last verified October 2026; the page names no clinician type.