Case Name: STATE of Louisiana v. Antonio A. ROMERO and Jesusa N. Romero
Court: Louisiana Supreme Court
Jurisdiction: Louisiana
Decision Date: 1990-04-06
Citations: 574 So. 2d 330
Docket Number: Nos. 89-K-0037, 89-K-0038
Parties: STATE of Louisiana v. Antonio A. ROMERO and Jesusa N. Romero.
Judges: CALOGERO, J., dissents for reasons assigned by WATSON, J.
Reporter: Southern Reporter, Second Series
Volume: 574
Pages: 330–343

Head Matter:
STATE of Louisiana v. Antonio A. ROMERO and Jesusa N. Romero.
Nos. 89-K-0037, 89-K-0038.
Supreme Court of Louisiana.
April 6, 1990.
Rehearing Denied Sept. 13, 1990.
William J. Guste, Jr., Atty. Gen., Cynthia Killingsworth, Glen Petersen, Asst. Attys. Gen., for the State.
Thomas Lorenzi, Godwin, Roddy, Loren-zi, Watson & Sanchez, Clifford Newman, Newman, Thibodeaux & Marshall, Lake Charles, Skipper Drost, Sulphur, for Antonio and Jesusa Romero.

Opinion:
DIXON, Chief Justice.
Defendant physicians, Dr. Antonio Romero and Dr. Jesusa Romero, were charged with sixty-seven and thirty-three counts of Medicaid fraud under R.S. 14:70.1, respectively. After a complicated and protracted jury trial, Dr. Antonio Romero was convicted on sixty counts and Dr. Jesusa Romero on twenty-eight counts. Defendants were convicted of making false claims totaling $1863.68. Each defendant was sentenced to five years at hard labor on each count, to run concurrently, but each was given a suspended sentence and placed on probation. On appeal, thirty-one of Dr. Antonio's sixty convictions were reversed. State of Louisiana v. Romero, 533 So.2d 1264 (La.App. 3d Cir.1988). The remaining twenty-nine counts were affirmed, as were all of Dr. Jesusa's convictions. Both the state and the defendants are before this court on writs. State of Louisiana v. Romero, 541 So.2d 879-80 (La.1989).
The Romeros, husband and wife, originally from the Philippines, were practicing medicine in Akron, Ohio, when DeQuincy Memorial Hospital contacted them in 1980 and asked that they relocate in Louisiana. Inducements included staff positions at the hospital and assistance in setting up their practice. In return, the Romeros were required to enroll in the Louisiana Medical Assistance Program (Medicaid) and to accept Medicaid recipients as patients. Enrollment consists of a contract between the medical provider, such as defendants, and the state, whereby the provider agrees to abide by all state and federal regulations, including billing procedures.
Upon enrollment, a physician is issued a provider manual which contains the rules and regulations of the program, provides details on what is and is not covered by the program, and contains instructions on completing and submitting claims forms. The provider manual directs physicians to use certain codes found in Current Procedural Terminology (CPT) books printed by the American Medical Association. CPTs are used for billing purposes and provide the codes used in making a claim, such as billing procedure codes, diagnosis codes, service codes, and unit codes. Not all of the codes listed in the CPT books, have been adopted by the Medicaid system and the provider manuals do not indicate which CPT codes are used in Medicaid, but provide only a broad description of what is covered.
Medicaid neither covers all medical services and treatment, nor does it interact directly with providers. Instead, Louisiana contracts with private companies to act as its fiscal intermediary for claims processing, disbursement and direct contact with providers. Medical providers submit claims for payment to the fiscal intermediary and, if approved, the intermediary issues a check to the provider. The provider must use the appropriate codes and information from the identification cards presented by eligible Medicaid recipients. The claims form is first submitted to the recipient's primary health insurer, if any, and then the claim is transferred, or "crossed over," to Medicaid's fiscal intermediary. Each claim is assigned an internal control number (ICN). The status of each claim form submitted is reflected in remittance advice statements sent to providers. On these statements appear the patient's name, the date of service, the procedure code for the service rendered, the ICN and information advising whether the claim is approved, rejected or held. Payment checks are accompanied by remittance advice statements, which in addition to the information above, include date of payment, the amount paid and the check number.
It is the state's contention that the defendants committed acts of Medicaid fraud in 1983, 1984 and 1985, through the following billing schemes: (1) over billing office visits by billing for a comprehensive visit when a lesser level of service was rendered; (2) billing for follow-up visits for patients released from the hospital, although the services were never rendered; (3) billing for visits to patients at Greenhill Nursing Home, which were never made; (4) billing for emergency room visits when telephone orders had been given; and (5) billing telephone calls as consultation.
Greenhill Documents
In their first assignment of error, both the state and defendants address the admissibility of medical records obtained from the Greenhill Nursing Home. The state introduced these documents at trial to prove Dr. Antonio committed Medicaid fraud by submitting claims for medical services to Greenhill residents which he never provided. The documents were charts compiled to record the progress of Greenhill patients and consisted of nurses' notes, progress notes, physician order sheets and doctors' orders sheets. The state called Theresa Decker, the custodian of the documents, to testify; she maintained that all pertinent information concerning a patient was contained in these documents, including entries documenting all doctor visits. The state asserted that the absence of such an entry would establish that Dr. Antonio did not make patient visits for which he billed Medicaid.
The admissibility of the documents is governed by the hearsay rule and exceptions to that rule. At the time of trial, hearsay was defined jurisprudentially.
" 'Hearsay evidence is testimony in court, or written evidence, of a statement made out of court, the statement being offered as an assertion to show the truth of matters asserted therein, and thus resting for its value upon the credibility of the out-of-court asserter. C. McCormick, Evidence, § 246 (Cleary ed. 1972).' " State v. Shoemaker, 500 So.2d 385, 388 (La.1987); State v. Martin, 356 So.2d 1370, 1373-74 (La.1978).
The defense objected to the introduction of these documents as hearsay, while the state maintained they fell under exceptions to that rule and were therefore admissible. The extent of the confusion and controversy surrounding these documents is illustrated in the lower court rulings with respect to this evidence.
Initially, the trial court excluded these documents, stating that they were unreliable and untrustworthy. The state applied for writs and the court of appeal reversed and set aside the trial court ruling, stating that defendants' objections were more properly addressed to the weight to be accorded the evidence. State v. Romero, 533 So.2d 1264 (La.App. 3d Cir.1988). This court subsequently denied defendants' writs, reserving to defendants the right to raise the issue if convicted. State v. Romero, 514 So.2d 467 (La.1987). The trial court then permitted the introduction of these documents under the business records exception to the hearsay rule. On appeal, the court of appeal held that the admission of this evidence under the business records exception was improper. To establish a foundation for the admission of the Greenhill documents as business records, the state was required to show that the persons who made these records were genuinely unable to testify. State v. Monroe, 345 So.2d 1185 (La.1977). The court of appeal concluded that the state failed to show this, thereby failing to establish the proper foundation for the admission of this evidence. As a result, many of the Greenhill convictions were reversed. The court of appeal further held that although these documents were not admissible as business records, they could have been admitted under the hospital records exception to the hearsay rule, R.S. 13:3714 and 13:3715.1.
The state now contends that the appellate court erred because prosecutors satisfied all foundation requirements for admissibility under both the business records and the hospital records exception to the hearsay rule. It is the unreliability and un-trustworthiness of the Greenhill documents which render them inadmissible, thus the distinction between hospital and business records is irrelevant.
Hearsay evidence is inadmissible except under one of the statutory or well recognized exceptions. State v. Broussard, 391 So.2d 1167 (La.1980); State v. Sheppard, 350 So.2d 615 (La.1977); R.S. 15:434. Policy considerations underlying the traditional exclusion of hearsay at criminal trial relate to the reliability of the unsworn statement and potential prejudice to the accused in permitting a damaging out-of-court statement which cannot be tested for its basis in fact. State v. Arnold, 367 So.2d 324, 326 (La.1979); State v. Ford, 336 So.2d 817 (La.1976). Reliability and trustworthiness of hearsay evidence must be established before it may be admitted into evidence. "In all conceivable exceptions to the hearsay rule, the trustworthiness of the evidence is the primary criterion for admissibility.'' State v. Trull, 382 So.2d 960, 962 (La.1980). (Emphasis added).
Various factual findings lead to the conclusion that the Greenhill documents are untrustworthy. The foundation for the admission of these documents into evidence was established by Theresa Decker, the custodian of the documents and director of nursing at Greenhill Nursing Home. Decker, testifying for the state, recounted that the nursing staff was instructed and required to document in nurses' notes all pertinent information about a patient, including when a patient left on pass and returned, and when a patient was visited by a doctor. The nurses' notes were attached to a patient's charts and these charts were kept in the nurses' station. Decker testified that she had standing instructions with the staff to notify her whenever a doctor made rounds. She was on twenty-four hour call to the nursing home. Further testimony from Decker and other Greenhill nurses revealed glaring deficiencies in these documents.
The most critical deficiency in this documentation is evident in the manner by which the patient files were compiled. Under cross-examination, Decker acknowledged that she routinely removed patient charts to her office and occasionally took them home overnight so that they might be "thinned." By this she meant that pages of nurses notes, progress notes, physician order sheets, and doctors' orders sheets were regularly culled from patient charts when those charts became too thick. The documents were removed and placed in separate files which the state failed to present at trial. Decker also testified that other reports, patient plans, medication orders and monthly summary sheets were not provided at trial. The state thus attempted to prove a physician's absence with incomplete documentation.
The method of recordation of medical information used at Greenhill also renders these documents unreliable. During testimony from eight licensed practical nurses (LPNs), all current or former employees of Greenhill, inconsistencies and contradictions were exposed concerning the patient records which undermined the integrity and reliability of these records.
LPN Bonnie Cryer acknowledged that patient charts were missing occasionally from the nurses' station. Her practice was to take notes, record patient information in "jot books," and later transcribe that information to the patient charts when found. LPN Eva McQeen stated the charts would be missing for no more than a couple of weeks and would often turn up in another patient's charts. Her practice was to begin a new page of nurses' notes, patient's chart, or whatever was required. LPN Peggy Bell never received instructions as to what should be recorded in nurses notes. In direct contradiction to Decker, she stated that there was neither procedure nor requirement to notify Decker when a doctor made rounds. She used "jot books" when patient charts could not be found. LPN Bernice McCoy testified that nurses' notes were not kept with the patient charts, but in a cardex at the nurses' station. LPN Judith Littlejohn stated that patient charts were not carried on rounds with doctors, but that she would take notes on a separate piece of paper and later transfer them to the nurses' notes. LPN Lisa Bushnell testified that no one was responsible for the "sign out" book that patients were to fill in when they left or returned to the premises. LPN Elsie Ramos stated that missing charts were usually found in Decker's office. Ramos' practice was to take notes in the "jot book" or in a pocket notebook she carried. Finally, LPN Shirley Myers testified that charts were missing at times; that sometimes they could be found in Decker's office; and that sometimes they could not be found at all. When this happened, it was her practice to begin with a new page of nurses' notes.
These documents have striking shortcomings, as established through nurses' testimony and on the face of the documents themselves. The staff had wide discretion with respect to entries made in nurses' notes. The notes bore numerous strike overs and errors as to times, dates, even years. Some notes, which were introduced to prove that Dr. Antonio was absent on a given day, would cover up to a five and one-half month time period on one side of a sheet of paper, with an entire month separating entries.
When combined with the disappearance of patient charts for extended periods of time, this evidence casts grave doubt upon the reliability of the notes and clearly establishes them as untrustworthy.
In determining whether erroneous admission of evidence requires reversal of a defendant's conviction, the proper standard is whether there is a reasonable possibility that the evidence might have contributed to the verdict, and whether the reviewing court is prepared to state beyond a reasonable doubt that it did not. Chapman v. California, 386 U.S. 18, 87 S.Ct. 824, 17 L.Ed.2d 705 (1967); State v. Walters, 523 So.2d 811 (La.1988); State v. Green, 493 So.2d 1178 (La.1986); State v. Gibson, 391 So.2d 421 (La.1980).
In counts involving the Greenhill documents, the state relied on the correlation of dates and entries in these documents to establish that Dr. Antonio did not make the nursing home visits claimed. These records and testimony from its authors were the only evidence introduced on these counts. It is clear that without the Greenhill documents, there is insufficient evidence to support convictions on these counts. Accordingly, and for reasons stated above, all counts involving the introduc tion of Greenhill documents are dismissed: Counts 6, 7, 22-27, 35-47, 49, 51-55 and 57-78.
Defendants would have us extend this ruling and reverse all convictions, arguing that the admission of these documents was so prejudicial as to require reversal on all counts. The state has presented independent evidence on the remaining counts sufficient to support those convictions. Dr. Jesusa was never linked to the Greenhill documents, nor did the state attempt to use those documents in any of the counts against her. None of the remaining counts against Dr. Antonio involved these records, nor were they introduced to support any conviction other than those already dismissed. There is no reasonable possibility that the introduction of the Greenhill documents contributed to the convictions on the remaining counts against Drs. Antonio or Jesusa Romero.
Other Crimes
Defendants assert that the trial court erred in admitting evidence of "other crimes" at trial. In an attempt to prove specific intent, the state introduced evidence of billing improprieties, or other crimes, by the Romeros with non-Medicaid patients. The state introduced this evidence under the authority of R.S. 15:445 and 15:446.
"In order to show intent, evidence is admissible of similar acts, independent of the act charged as a crime in the indictment, for though intent is a question of fact, it need not be proven as a fact, it may be inferred from the circumstances of the transaction." R.S. 15:445.
"When knowledge or intent forms an essential part of the inquiry, testimony may be offered of such acts, conduct or declarations of the accused as tend to establish such knowledge or intent and where the offense is one of a system, evidence is admissible to prove the continuity of the offense, and the commission of similar offenses for the purpose of showing guilty knowledge and intent, but not to prove the offense charged." R.S. 15:446.
Before evidence of other crimes is admitted as proof of intent, three prerequisites must be satisfied: (1) the prior acts must be similar, (2) there must be a real genuine contested issue of intent at trial, and (3) the probative value of the evidence must outweigh its prejudicial effect. State v. Kahey, 436 So.2d 475, 488 (La.1988).
By introducing evidence of similar billing improprieties with non-Medicaid patients, the state demonstrated a systematic practice followed by the Romeros which was highly relevant to the question of intent to defraud, a .material issue at trial. The state advised defendants before trial of its intent to show knowledge, system and intent in connection with specified patients of defendants. The defendants requested and received jury instruction on the purpose for which this evidence could be received, thus minimizing the prejudicial effect of such evidence. The trial court did not err in allowing the introduction of this evidence into the record.
Rebuttal Witnesses
Defendants contend that the state's failure to call rebuttal witnesses deprived them of their right to confrontation, cross-examination, due process and a fair trial. Amy Fontenot was called as a witness by the defense. She testified that Dr. Antonio had treated her non-ambulatory daughter in the parking lot of their offices, rather than require that she be brought inside. She stated that she was visited at home by one of the state's attorneys but that she ordered him to leave and threatened to call the police after he called her a liar. She was then cross-examined by Glen Petersen, the same state's attorney complained of. He sought to impeach her by demonstrating that she had lied on direct examination and that her ability to recall details of her conversation with state investigators was poor. The state requested that all investigators with whom Fontenot had contact be sequestered so they could later be called on rebuttal, if needed. The state did not call any witness to rebut her testimony. Defendants now contest the state's failure to do so.
The prosecution has the right to rebut evidence adduced by the defendant at trial. State v. Williams, 445 So.2d 1171 (La.1984); R.S. 15:282. In a criminal prosecution the state does not and cannot know what evidence the defendant will use until it is presented at the trial of the case. It is for this reason that the state is given the right of rebuttal. State v. Monroe, 205 La. 285, 17 So.2d 331 (1944). The presentation of rebuttal witnesses is the state's right. The prosecution is under no obligation to call rebuttal witnesses. This argument is without merit.
Improper Cross-Examination
Defendants allege that the scope of the state's cross-examination was improper and, more particularly, that Petersen should not have conducted the cross-examination of Fontenot, for by doing so he cast her credibility in direct conflict with his. Although care should be exercised not to exceed the proper bounds by impeaching a witness as to collateral facts or irrelevant matters under R.S. 15:494, mere doubts as to the propriety of the extent of the cross-examination are always resolved in favor of the cross-examination. State v. Weathers, 320 So.2d 895, 898 (La.1975), citing State v. Bertrand, 167 La. 373, 119 So. 261 (La.1928). Although it would have been preferable for the state to cross-examine Fontenot with someone other than Petersen, the defendants fail to show, nor is there any indication from the record, that this caused any prejudice whatsoever. Fontenot's testimony went uncontradicted and was accepted as being truthful and credible. This assignment is without merit.
Evidence of Specific Intent
In their final assignment of error, defendants contend that the prosecution failed to prove guilt beyond a reasonable doubt, particularly the requirement of specific intent.
Medicaid fraud is a specific intent crime. Specific intent is a state of mind, and, as such, need not be proved as fact, but may be inferred from the circumstances of the transaction and actions of the accused. State v. McDermitt, 406 So.2d 195 (La.1985); State v. Williams, 383 So.2d 369 (La.1980).
The federal constitutional standard of appellate review for a sufficiency of evidence claim is whether, after viewing the evidence in a light most favorable to the prosecution, a rational trier of fact could have found the essential elements of the crime proved beyond a reasonable doubt. Jackson v. Virginia, 443 U.S. 307, 99 S.Ct. 2781, 61 L.Ed.2d 560 (1979).
To prove that defendants billed for comprehensive office visits when lesser services were rendered, the state presented a qualified expert, Dr. Henry Rothchild, a professor of medicine at Louisiana State University Medical School with a private practice in internal medicine and geriatrics, who testified about notes taken by the Romeros during each questioned visit. It was his expert opinion that the notes were clearly deficient and did not reflect a comprehensive office visit. Further testimony from nurses at the Romeros' office established that they were instructed by the Romeros to always bill office visits as comprehensive office visits, regardless of the services actually rendered. This was true even after the nurses told the doctors that this procedure was improper. One comprehensive visit charge was established independently of Dr. Rothchild's testimony. This involved a comprehensive office visit billed to Zenia Dove. The state proved through testimony of office nurses and Dove's caretaker that Dove never visited their office because she was bedridden. The caretaker also stated that Dove was never visited by either doctor. Viewing the evidence in a light most favorable to the prosecution, the jury could have found the defendants guilty beyond a reasonable doubt on the counts involving comprehensive office visits.
The state also proved that defendants billed Medicaid for follow-up office visits after a patient's release from the hospital, although the follow-up visit never occurred. One count against Dr. Antonio and two counts against Dr. Jesusa involved alleged follow-up visits provided to Dove. Again the state introduced testimony by Dove's caretaker and nurses to prove that these services were never provided. To prove a final follow-up visit count against Dr. Jesusa, the state introduced into evidence records from Humana Hospital of Lake Charles and DeQuincy Memorial Hospital. Dr. Jesusa billed Medicaid for a follow-up office visit of a patient who was still hospitalized, according to those records. On this evidence the jury could have found specific intent beyond a reasonable doubt.
To prove that the defendants billed for emergency room visits which they never made, the state produced testimony from emergency room nurses who testified from their notes. All testified that their notes would have indicated a visit from the doctor, yet no notation of such a visit existed. The state also established, through emergency room nurses' testimony, that both doctors made a practice of calling in phone orders to the emergency room and billing those calls as emergency room visits. A reasonable person would know that a telephone call would not be a proper substitute for an emergency room visit, and therefore should not be billed as one. On this evidence, in a light most favorable to the state, the jury could have found specific intent beyond a reasonable doubt.
Finally, we address the question of specific intent with respect to the counts in which the state proved the defendants improperly billed telephone calls as consultations. The state had Department of Health and Human Resources Assistant Director for Medicaid, Carolyn Maggio, testify. She stated that providers were required to become familiar with their provider manual. This manual contains the rules, regulations and definitions of the program; provides details on what is and is not covered; and contains instructions on completing and submitting forms. Maggio testified that this manual prohibits billing of telephone calls and that a consultation requires "hands on" contact by the provider/doctor, or at least, "face to face interaction." The state introduced a looseleaf binder seized from the Romero clinic, although it was never determined to be a complete provider manual. This manual provides that all coding used in claim forms was to be taken from Current Procedural Terminology (CPT) books. Having reviewed the provider manual in the record, we find nothing in it that supports the assertion that phone calls may not be billed as consultations. On the contrary, the CPT books tend to support the defendants' position. We found that all of the CPT books provided procedure codes for telephone consultations. Therefore, a provider, relying on the provider manual and the CPT books, could reasonably conclude that telephone consultations could be billed to Medicaid. The state did, however, establish through testimony and through the provider manual, that providers could not "consult" their own patients. The following definition of consultation is found in the provider manual:
"The Medical Assistance Program defined a consultation when a physician's opinion or advice is requested by another physician or other appropriate source in order to aid the referring source in evaluating or managing the patient.
The consulting physician must enter the referring physician's name in Item 19 of the claim form when billing for a consultation service.
Physician visits should not be billed as a consultation when:
The physician has already seen the patient on a recent consultation for the same condition.
The physician has recently provided medical care to the patient as treating physician.
The physician intends to follow the patient and will be billing as a treating physician for subsequent medical care." (S-118, p. 4-20).
The medical records of all telephone consultation patients were entered into the record by the state. These clearly establish that Dr. Jesusa and Dr. Antonio had recently provided medical care to each of these patients as treating physician, and that they intended to follow each patient as a treating physician for subsequent medical care at the time of the consultation. Viewed in a light most favorable to the prosecution, this evidence establishes that the jury could have found beyond a reasonable doubt that the doctors had the requisite intent to defraud Medicaid.
Costs
The state contends that the appellate court erred in proportionately reducing costs assessed against defendants as to the convictions reversed on appeal. This issue is now moot since those convictions, and others, have been dismissed. A defendant who is convicted of an offense is liable for all costs of the prosecution or proceedings, but a defendant is not liable for costs if he is acquitted or if the prosecution or proceeding is dismissed. C.Cr.P. 887 A. Accordingly, no costs will be assessed to defendants on any convictions dismissed on appeal or by this court.
For reasons assigned, the following counts against Dr. Antonio Romero are dismissed: Counts 6, 7, 22-27, 35-47, 49, 51-55 and 57-78. The convictions and sentences on his remaining counts are affirmed: Counts 1, 2, 3, 4, 5, 8, 21, 28, 29, 30 and 33. Dr. Jesusa Romero's convictions and sentences are affirmed.
CALOGERO, J., dissents for reasons assigned by WATSON, J.
WATSON and LEMMON, JJ., dissent and assign reasons.
. "A. The crime of Medicaid fraud is the act of any person, who, with intent to defraud the state through any medical assistance program created under the federal Social Security Act and administered by the Department of Health and Hospitals:
(1) Presents for allowance or payment any false or fraudulent claim for furnishing services or merchandise; or
(2) Knowingly submits false information for the purpose of obtaining greater compensation than that to which he is legally entitled for furnishing services or merchandise; or
(3) Knowingly submits false information for the purpose of obtaining authorization for furnishing services or merchandise.
B. Whoever commits the crime of Medicaid fraud shall be imprisoned, with or without hard labor, for not more than five years, or may be fined not more than ten thousand dollars, or both." R.S. 14:70.1.
. The court of appeal reversed the conviction and ordered a retrial on Count 50; however, according to the verdict order form, the jurors acquitted Dr. Antonio on that count.
. While it is unclear from the record when the Romeros received their provider manual or whether they ever possessed an updated provider manual, it is clear that they had significant problems in obtaining one and had to make numerous requests to the fiscal intermediary before receiving one.
. Each different service and diagnosis rendered must be itemized in code on the claim. For example, there are eleven gradations of "office visit" listed in the CPT (1986), with five levels of service for new patients and six for established patients. There are also hundreds of diagnosis codes.
. Although written by the Department of Health and Human Resources, the fiscal intermediary has the responsibility to print and distribute provider manuals, as well as updates and revisions.
. This court has fashioned the following formula for the admission of business records:
"A permanent record made in the ordinary course of business, by a person unavailable for testimony, from personal knowledge of the facts recorded or from information furnished by one having a business duty to observe and report the facts, ." State v. Monroe, supra at 1188.
The Monroe court cautioned that business records could be admitted as proof of their assertions only if the state proved "that the person who made the record is genuinely unavailable for testimony, that he has no strong motive to misrepresent, and that in all probability the evidence is trustworthy." State v. Monroe, supra at 1190.
. "Jot books" were used by nurses as a supplement to shift reports to convey information omitted in reports. Decker stated that these notebooks were used as ancillaries to nurses' notes.
. The following codes were found in CPT (1985) at Medicine, p. 41:
"99013 Telephone call for consultation or medical management; simple or brief (eg, to report on test and/or laboratory results; to clarify or alter previous instructions; to adjust therapy)
99014 intermediate (eg, to provide advice to an established patient on a new problem; to initiate therapy that can be handled by telephone; to discuss results of tests in detail)
99015 lenthy or complex (eg, lengthy counseling session with anxious or distraught patient; detailed or prolonged discussion with family member regarding seriously ill patient)"