Evaluation and Management
Documentation Guidelines
Michael Leeson, M.D., Ph.D.
Chief Medical Officer
Kansas Health Solutions, LLC
(mleeson@khs-ks.org)
Focus of Today’s Program
• Rationale for using E/M coding
• Benefits of E/M coding
• Key differences between the 1995 and
1997 CMS documentation guidelines for
E/M services.
• Documentation guidelines for select
Evaluation and Management (E/M) codes
available for use by prescribers
Where Do I Find Information About
E/M Documentation Requirements?
• Current CPT Manual
• CMS Website
– 1995 Guidelines:
http://www.cms.hhs.gov/MLNProducts/downloads/1995dg.
pdf
– 1997 Guidelines:
http://www.cms.hhs.gov/MLNProducts/downloads/master1.
pdf
• HCFA Draft worksheet:
http://www.aafp.org/online/en/home/publications/journals/fpm/
collections/fpmmedicare/meddecisions.html
Key CPT Codes Available for
Psychiatric Medication Clinic Visits by
Prescribers
• Pharmacologic Management (90862)
• Therapy with E/M (90805, 90807, 90809 as
well as 90811, 90813, 90815)
• E/M Codes
– New Outpatient Office Visit
(99201, 99202, 99203, 99204, 99205)
– Established Outpatient Office Visit
(99211, 99212, 99213, 99214, 99215)
– Outpatient Consultation
(99241, 99242, 99243, 99244, 99245)
Why Use the E/M Codes?
• Accurately capture work value of sessions
• Accommodate prescriber services beyond
the scope of a typical 90862
• Reimbursement rate higher than 90862 for
99214 and 99215
1995 Versus 1997 Guidelines
• CMS allows prescribers to use EITHER the
1995 or 1997 guidelines.
• Elements of 1995 CANNOT be intermixed
with elements of 1997 guidelines in a single
service note.
Key Differences Between 1995
and 1997 Guidelines
1995
Guidelines
1997
Guidelines
History
Only elements are
counted
Status of chronic
conditions may substitute
for elements
Examination
Somewhat subjective
Highly defined
examination bullets
Medical Decision Making
Same in 1995 and 1997
Same in 1995 and 1997
When KHS Reviews E/M
Documentation…
• Auditors will “score” the service by both
1995 and 1997 guidelines
• The “score” that is most advantageous to
the Provider will be used
CMS-Defined Core Components of
E/M Documentation
•
•
•
•
•
•
History
Examination
Medical Decision Making
Counseling and Coordination of Care
Nature of Presenting Problem
Time
E/M Coding: Key Components in
Selecting Which Service was Rendered
• History
• Examination
• Medical Decision Making
OR
• Documentation based on time, but ONLY IF
counseling or coordination of care
dominated the session
Counseling and Coordination of
Care
• Counseling, in this context, is NOT
psychotherapy
• In an outpatient encounter, the Counseling
and Coordination of Care MUST occur
during the face-to-face portion of the
encounter
Counseling and Coordination of
Care Would Include:
• Education (diagnosis, prognosis, treatment options)
• Discussion of potential risks and benefits of proposed
treatments
• Education about self-management techniques
• Review of laboratory results, recommended
interventions (i.e., diet, exercise, referral)
• Work with family or other care providers to facilitate
Member’s treatment
• Etc.
To Code by Time Spent
Counseling and Coordinating Care
• Start and Duration must be documented
• Notation must be included that more than
50% of the face-to-face visit was spent in
Counseling or Coordination of Care
• Key topics of Counseling or Coordination
must be documented
• Select the proper code based on the time of
the full face-to-face portion of the encounter
Typical Time Spent Face-ToFace
New Outpatient visit
Established Outpatient visit
•
•
•
•
•
•
•
•
•
•
99201
99202
99203
99204
99205
10 minutes
20 minutes
30 minutes
45 minutes
60 minutes
99211
99212
99213
99214
99215
5 minutes
10 minutes
15 minutes
25 minutes
40 minutes
(For typical times spent face-to-face during an outpatient
consultation, refer to the current CPT manual.)
Mr. X
Start time: 11:15am
6/12/09
Face-to-face time: 30 minutes
Goal: Mr. X will have an euthymic mood 90% of the time.
CC: Mr. X returns for routine follow-up. He notes “I can’t sleep.”
HPI:Mr. X said he had been sleeping poorly for the past 8 days with racing thoughts and excessive energy.
He noted impulsivity in terms of unplanned travel and spending sprees. He said he had been taking his
lithium as prescribed and denied side effects. He denied any suicidal thoughts, citing religion and family
as chief deterrents. He presented no evidence of dangerousness.
MSE: Mr. X was meticulously groomed and was dressed extravagantly for the occasion. He maintained
good eye contact and was cooperative. He noted a “wonderful” mood and displayed a bright and
expansive affect. He denied SI/HI/AH/VH, and there was no overt attention to internal stimuli. His
speech was increased in volume and amount with marked flight of ideas.
Lab: Li level on 6/10/09 was 0.3
Impression: Bipolar I Disorder, Most Recent Episode Manic, Severe, without Psychotic Features;
acute decompensation
Plan: Over 50% of the time was spent in counseling and coordination of care. Topics included education
about mania, discussion of how to recognize worsening mania, his subtherapeutic lithium level, potential
risks/benefits of increasing lithium dose, as well as lifestyle modifications needed for safe use of lithium.
We reviewed signs and symptoms of lithium toxicity that would warrant a call to the office or visit to the
emergency room. He expressed understanding and gave consent, so we will increase his lithium
carbonate to 600mg twice daily. He will RTC 1 week or sooner prn.
Which is the Correct Code to Bill?
Established Outpatient visit, typical time face-to-face:
99211
99212
99213
99214
99215
5 minutes
10 minutes
15 minutes
25 minutes
40 minutes
←
If Coding is NOT Based on Counseling
and Coordination of Care
• Key components to determine level of service
– History
– Examination
– Medical Decision Making
• For Consultations and New Patient, all 3
components are used to determine level of
service
• For Office or other Outpatient visits for
ESTABLISHED patients, the TWO highest scoring
components determine level of service
Extent of History and Examination
• History
– Problem Focused
– Expanded
Problem Focused
– Detailed
– Comprehensive
• Examination
– Problem Focused
– Expanded
Problem Focused
– Detailed
– Comprehensive
Medical Decision Making
•
•
•
•
Straightforward
Low complexity
Moderate complexity
High complexity
Example: Established Outpatient
Coding
CPT Code
History
Examination
MDM
Typical Time
99211
N/A
N/A
N/A
5 minutes
99212
Problem
Focused
Problem
Focused
Straightforward
10 minutes
99213
Expanded
Problem
Focused
Expanded
Problem
Focused
Low Complexity 15 minutes
99214
Detailed
Detailed
Moderate
Complexity
25 minutes
99215
Comprehensive
Comprehensive
High
Complexity
40 minutes
For Established Outpatient Office Visits, 2 of 3 components (history, exam,
MDM) must be met or exceeded. For Consultations and New Outpatient Office
Visits, all 3 components must be met. Coding based on time (Counseling or
Coordination of Care) is the exception.
Coding the History
Components of History
• Chief Complaint
• History of
Present Illness
– Brief
– Extended
• Review of
Systems
– None
– Problem
Pertinent
– Extended
– Complete
• Past, Family,
and/or Social
History
– None
– Pertinent
– Complete
Measuring the History
Level of History HPI
ROS
PFSH
Problem Focused
Brief
None
None
Expanded
Problem Focused
Brief
Problem Pertinent
None
Detailed
Extended
Extended
Pertinent
Comprehensive
Extended
Complete
Complete
The Extent of the History
• A Chief Complaint is required for every level of
service.
• The 8 recognized “elements” of HPI include:
Location, Quality, Severity, Duration, Timing,
Context, Modifying Factors, and Associated
Signs and Symptoms.
• 1997 guidelines allow status of chronic conditions
to be substituted for “elements” of HPI. 1995
guidelines do not allow substitution.
Recognized Elements of HPI
Location
Quality
Severity
Duration
Timing
Context
Modifying Factors
Associated Signs
and Symptoms
Scoring the HPI
Level of HPI
Brief
Extended
1995 Guidelines
1997 Guidelines
Chief Complaint
+
1-3 “Elements”
Chief Complaint
+
1-3 “Elements” or status
of 1-2 chronic conditions*
Chief Complaint
+
4 or more “Elements”
Chief Complaint
+
4 or more “Elements” or
status of 3 or more
chronic conditions
(*Use of chronic conditions for the 1997 Brief HPI is a KHS interpretation;
other managed care organizations may or may not subscribe to this
Interpretation.)
Review of Systems
Systems Recognized by 1995 and 1997 Guidelines
Constitutional
GI
Psychiatric
Eyes
GU
Endocrine
Ears, Nose, Mouth, Throat
Musculoskeletal
Hematologic/Lymphatic
Cardiovascular
Skin and/or breast
Allergic/Immunologic
Respiratory
Neurological
Level of ROS
Number of Systems Reviewed
None
0
Problem Pertinent
1 system
Extended
2-9 systems
Complete
10 or more systems (or some
systems and a statement all
others negative)
Past, Family, and/or Social History
• Three history components recognized:
– Patient’s Past History
– Family History
– Social History
• At least one specific item in a particular area must be
documented for a “Pertinent” PFSH
• At least one specific item 2 or 3 of the areas must be
documented for a “Complete” PFSH
– 2 areas required for an established outpatient
– 3 areas required for consultation or new outpatient
Scoring the PFSH
Level of PFSH
Areas of PFSH for
Areas of PFSH for New
Established Outpatients Outpatients or
New/Established
Consults
None
0
0
Pertinent
1 or more
1 or more
Complete
2 or more
3
Putting the History Together
Level of History
HPI
ROS
PFSH
Problem Focused
Brief
None
None
Expanded
Problem Focused
Brief
Problem Pertinent
None
Detailed
Extended
Extended
Pertinent
Comprehensive
Extended
Complete
Complete
Mr. X
Start time: 11:15am
6/12/09
Face-to-face time: 30 minutes
Goal:
Mr. X will have an euthymic mood 90% of the time.
CC:
Mr. X returns for routine follow-up. He notes “I can’t sleep.”
HPI:
Mr. X reported severely worsening sleep for the past 8 days including no sleep at all for at least 72
hours. He said this had occurred in the context of stress over an upcoming family reunion. He noted associated
symptoms of starting excessive numbers of projects, racing thoughts, shopping sprees, an unplanned 3-day trip,
and friends commenting he talks too much. He reported using lithium as prescribed with tremor as his only
side effect.
Collateral: Mr. X’ case manager indicated that over the past week, he had noticed that Mr. X had persistently
pressured speech, grandiose business plans, and occasional irritability that is unusual for him.
PFSH:
Mr. X had elevated transaminases with divalproex sodium in the past. He and his wife have recently
separated.
ROS:
GI: Denied any nausea, vomiting, or diarrhea since on Li
Endocrine: Denied any weight gain, constipation, or cold intolerance since on Li
Scoring the HPI
Elements of HPI
Location
Timing
Quality
Context
Severity
Modifying
Factors
Associated
Signs and
Symptoms
Duration
Level of
HPI
1997 Guidelines
Brief
Chief Complaint
+
1-3 “Elements” or status of 1-2
chronic conditions*
Extended
Chief Complaint
+
4 or more “Elements” or status
of 3 or more chronic conditions*
(*Use of chronic conditions for the 1997 Brief HPI is a KHS interpretation;
other managed care organizations may or may not subscribe to this
Interpretation.)
Scoring the ROS
Level of ROS
Number of Systems Reviewed
None
Problem
Pertinent
0
1 system
Extended
Complete
2-9 systems
10 or more systems (or some
systems and a statement all
others negative)
Scoring the PFSH
Level of
PFSH
Areas of PFSH for
Established Outpatients
None
0
Pertinent 1 or more
Complete 2 or more (PMH, SH)
Putting the History Together
Level of History
HPI
ROS
PFSH
Problem Focused
Brief
None
None
Expanded
Problem Focused
Brief
Problem Pertinent
None
Detailed
Extended
Extended
Pertinent
Comprehensive
Extended
Complete
Complete
Coding the Examination
Levels of Examination
Problem Focused
Expanded Problem Focused
Detailed
Comprehensive
Types of Examination
Type of Examination
1995 Guidelines
1997 Guidelines
General Multi-System
Available at all levels
Subjective scoring
Available at all levels
Objective scoring
Single System
Available for only
Problem Focused
Comprehensive
Specialty examination available
for all levels
Specific psychiatric exam
1995 Guidelines Examination
Level of Examination
Documentation
Requirements
Problem Focused
“A limited examination of the affected
body area or organ system”
Expanded Problem Focused
“A limited examination of the affected
body area or organ system and other
symptomatic or related organ system(s)”
Detailed
“An extended examination of the
affected body area(s) and other
symptomatic or related organ system(s)”
Comprehensive
“A general multi-system examination or
complete examination of a single organ
system”
(Must include 8 or more organ systems)
Quotations are from the CMS 1995 documentation guidelines:
http://www.cms.hhs.gov/MLNProducts/downloads/1995dg.pdf
1995 Documentation Guidelines
Recognized Body Areas
Head and face
Neck
Chest, breasts, axillae
Abdomen
Genitalia, groin, buttocks
Back and spine
Each extremity
1995 Documentation Guidelines
Recognized Organ Systems
Constitutional
Eyes
Ears, nose, mouth, throat
Cardiovascular
Genitourinary
Musculoskeletal
Skin
Neurologic
Respiratory
Gastrointestinal
Psychiatric
Hematologic, lymphatic,
immunologic
KHS Scoring of Examination by
1995 Guidelines
Level of Examination
Documentation Requirement
Problem Focused
≥ 1 element in any body area or organ
system
Expanded Problem Focused
≥ 1 element in any body area or organ
system AND ≥ 1 element in any additional
organ system
Detailed
Extended examination of the affected
area or organ system AND extended
examination of ≥ 1 additional organ
system
Comprehensive
Documentation of examination of ≥ 8
organ systems OR a complete psychiatric
specialty examination
KHS Scoring by 1995 Guidelines:
Complete Psychiatric Specialty Exam
All of the following must be
documented
Speech
Memory (remote and recent)
Thought Processes
Attention and Concentration
Associations
Language
Abnormal or psychotic thoughts or lack
thereof
Fund of Knowledge
Insight and Judgment
Mood and Affect
Orientation (time, place, person)
1997 Guidelines:
General Multisystem Examination
Level of Examination
Documentation
Requirements
Problem Focused
Expanded Problem Focused
Detailed
1-5 bulleted elements
≥6 bulleted elements
≥2 bulleted elements from
each of six areas/systems
OR
≥12 bulleted elements from
≥2 areas/systems
≥2 bulleted areas from each
of ≥9 areas/systems
Comprehensive
1997 Documentation Guidelines
Recognized Body Areas and Organ
Systems
Constitutional
Eyes
Gastrointestinal/Abdomen
Genitourinary
Ears, nose, mouth, throat
Neck
Respiratory
Cardiovascular
Lymphatic
Musculoskeletal
Skin
Neurologic
Chest, breasts
Psychiatric
1997 Guidelines Psychiatric
Specialty Examination
Reproduced from the CMS 1997 documentation guidelines:
http://www.cms.hhs.gov/MLNProducts/downloads/master1.pdf
Scoring the 1997
Psychiatric Specialty Examination
Level of Examination
Documentation
Requirements
Problem Focused
1-5 bulleted elements
Expanded Problem Focused
6-8 bulleted elements
Detailed
≥9 bulleted elements
Comprehensive
Each element in a shaded box (the
psychiatric and constitutional areas)
+
At least one element in the unshaded
box (the musculoskeletal area)
Vitals:
Weight: 220 lbs
Pulse: 78 and regular
Blood Pressure: 123/76
Appearance:
Well developed and well nourished white male in no apparent physical distress. He was well
groomed and overdressed for the occasion.
Musculoskeletal:
Muscle strength was 5/5 throughout with normal tone.
There was a moderate postural tremor noted in both hands with increased intention tremor.
Psychiatric:
Speech was increased in volume and rate. Thought content was logical and abstraction was intact
by testing with pairs (apple + banana = fruit). Marked flight of ideas was present. There were no
loose associations noted. He denied SI/HI/AH/VH and there was no overt attention to internal
stimuli. Judgment appeared impaired in terms of unplanned travel and spending sprees but insight
into his mania appeared intact.
Mr. X was A&O X 4. Immediate and 5 minute recall were 3/3. He was able to name the past 4
United States presidents. He had difficulty attending to the interview but responded well to
redirection. He was able to name 3 common items. He discussed recent events related to the
economy. He noted a “wonderful” mood and demonstrated a bright and expansive affect.
1997 Guidelines Psychiatric
Specialty Examination
→
→
→
→
→
→
→
→
→
→
→
→
→
→
←
Reproduced from the CMS 1997 documentation guidelines:
http://www.cms.hhs.gov/MLNProducts/downloads/master1.pdf
Medical Decision Making
1995 versus 1997 Guidelines:
Medical Decision Making
Medical Decision Making (MDM) is scored
identically for 1995 and 1997 guidelines
Levels of Medical Decision Making
Straightforward
Low Complexity
Moderate Complexity
High Complexity
Scoring Medical Decision Making
• Components of MDM
– Number of diagnoses considered and/or management
options considered
– Amount and/or complexity of data ordered or reviewed
– Level of risk for complications, including morbidity and
mortality
• Each component is individually scored
• Level of MDM defined by the highest scores in 2 of
the 3 MDM components
Medical Decision Making:
Must Meet or Exceed 2 of the 3
Number of
diagnoses or
management
options
Amount and/or
complexity of
data to be
reviewed
Risk of
complications
and/or
morbidity or
mortality
Type of
decision
making
Minimal
Minimal or none
Minimal
Straightforward
Limited
Limited
Low
Low
Complexity
Multiple
Moderate
Moderate
Moderate
Complexity
Extensive
Extensive
High
High
Complexity
CMS 1997 documentation guidelines:
http://www.cms.hhs.gov/MLNProducts/downloads/master1.pdf
Medical Decision Making
• Scoring is addressed in a concrete manner
in neither the 1995 nor the 1997
documentation guidelines
• A draft score sheet had been released by
HCFA in the past.
• Draft score sheet contents referenced at:
http://www.aafp.org/online/en/home/publicat
ions/journals/fpm/collections/fpmmedicare/
meddecisions.html
KHS: Scoring Diagnoses and
Treatment Options
Self-limiting and/or minor problem, maximum of 2
problems
1 point each
Condition already diagnosed by provider and improved
and/or stable
1 point each
Condition already diagnosed by provider and worsening
2 points each
Condition that is new to the provider without further
work-up planned, maximum of 1 problem
3 points
Condition that is new to the provider and further work-up
is planned
4 points each
Minimal
1 point
Limited
2 points
Multiple
3 points
Extensive
4 points
KHS: Scoring Amount and/or
Complexity of Data
Laboratory testing ordered and/or reviewed
1 point
Radiology testing ordered and/or reviewed
1 point
Medical testing ordered and/or reviewed
1 point
Discussion of results with physician who performed or interpreted the
test
1 point
Direct and independent review and interpretation of a specimen,
tracing, or image
1 point
each
Decision to obtain old records and/or collateral information
1 point
Review and written summary of old records and/or collateral
information
2 points
Minimal or none
≤1 point
Limited
2 points
Moderate
3 points
Extensive
≥4 points
Reproduced from the
CMS 1997
documentation
guidelines:
http://www.cms.hhs.gov/
MLNProducts/downloads
/master1.pdf
Mr. X (continued)
Laboratory: Li level 0.3 on 6/10/09
ECG: Received from PCP Dr. Y, done on 6/04/09 and noted by Dr. Y to be normal.
The ECG was reviewed today, and I concur with Dr. Y.
Impression:
Bipolar I Disorder, Most Recent Episode Manic, Severe, Without Psychotic Features
Acute decompensation
Plan:
We reviewed the potential risks and benefits of increase in LiCO3 to target mania,
including discussion of the risk of lithium toxicity and symptoms that would warrant an
immediate phone call to the clinic or trip to the emergency room. We also reviewed
lifestyle modifications for safe use of lithium. He expressed understanding and gave
consent, so the LiCO3 dose will be increased to 600mg po BID. He will RTC 1 week,
sooner prn.
Mr. X: Scoring Diagnoses and
Treatment Options
Self-limiting and/or minor problem, maximum of 2
problems
1 point each
Condition already diagnosed by provider and improved
and/or stable
1 point each
Condition already diagnosed by provider and worsening
2 points each
Condition that is new to the provider without further
work-up planned, maximum of 1 problem
3 points
Condition that is new to the provider and further work-up
is planned
4 points each
Minimal
1 point
Limited
2 points
Multiple
3 points
Extensive
4 points
Mr. X: Scoring Amount and/or
Complexity of Data
Laboratory testing ordered and/or reviewed
1 point
Radiology testing ordered and/or reviewed
1 point
Medical testing ordered and/or reviewed
1 point
Discussion of results with physician who performed or interpreted the
test
1 point
Direct and independent review and interpretation of a specimen,
tracing, or image
1 point
each
Decision to obtain old records and/or collateral information
1 point
Review and written summary of old records and/or collateral
information
2 points
Minimal or none
≤1 point
Limited
2 points
Moderate
3 points
Extensive
≥4 points
?
→
→
→
?
Reproduced from the
CMS 1997
documentation
guidelines:
http://www.cms.hhs.gov/
MLNProducts/downloads
/master1.pdf
Summarizing Medical Decision
Making for Mr. X
Number of
diagnoses or
management
options
Amount and/or
complexity of
data to be
reviewed
Risk of
complications
and/or
morbidity or
mortality
Type of
decision
making
Minimal
Minimal or none
Minimal
Straightforward
Limited
Limited
Low
Low
Complexity
Multiple
Moderate
Moderate
Moderate
Complexity
Extensive
Extensive
High
High
Complexity
Must meet or exceed 2 of the 3 items
for a given level
Summary:
Established Outpatient Coding
CPT Code
History
Examination
MDM
Typical Time
99211
N/A
N/A
N/A
5 minutes
99212
Problem
Focused
Problem
Focused
Straightforward
10 minutes
99213
Expanded
Problem
Focused
Expanded
Problem
Focused
Low Complexity 15 minutes
99214
Detailed
Detailed
Moderate
Complexity
25 minutes
99215
Comprehensive
Comprehensive
High
Complexity
40 minutes
For Established Outpatient Office Visits, 2 of 3 components (history, exam,
MDM) must be met or exceeded. For Consultations and New Outpatient Office
Visits, all 3 components must be met. Coding based on time (Counseling or
Coordination of Care) is the exception.
Coding Mr. X’ Outpatient Visit
CPT Code
History
Examination
MDM
Typical Time
99211
N/A
N/A
N/A
5 minutes
99212
Problem
Focused
Problem
Focused
Straightforward
10 minutes
99213
Expanded
Problem
Focused
Expanded
Problem
Focused
Low Complexity 15 minutes
99214
Detailed
Detailed
Moderate
Complexity
25 minutes
99215
Comprehensive
Comprehensive
High
Complexity
40 minutes
For Established Outpatient Office Visits, 2 of 3 components (history, exam,
MDM) must be met or exceeded. For Consultations and New Outpatient Office
Visits, all 3 components must be met. Coding based on time (Counseling or
Coordination of Care) is the exception.
What if….
• What if no ECG had been done or reviewed?
– Amount and/or complexity of data would be scored as
moderate
– Medical Decision Making would be scored as moderate
complexity
– The visit would be properly coded as a 99214
• Medical Necessity will determine if the ECG
should be done
– An ECG wouldn’t be ordered simply to allow a higher
code.
– If the ECG was needed, though, take credit for it!
Mr. X: Scoring Amount and/or
Complexity of Data
Laboratory testing ordered and/or reviewed
1 point
Radiology testing ordered and/or reviewed
1 point
Medical testing ordered and/or reviewed
1 point
Discussion of results with physician who performed or interpreted the
test
1 point
Direct and independent review and interpretation of a specimen,
tracing, or image
1 point
each
Decision to obtain old records and/or collateral information
1 point
Review and written summary of old records and/or collateral
information
2 points
Minimal or none
≤1 point
Limited
2 points
Moderate
3 points
Extensive
≥4 points
Summarizing Medical Decision
Making for Mr. X
Number of
diagnoses or
management
options
Amount and/or
complexity of
data to be
reviewed
Risk of
complications
and/or
morbidity or
mortality
Type of
decision
making
Minimal
Minimal or none
Minimal
Straightforward
Limited
Limited
Low
Low
Complexity
Multiple
Moderate
Moderate
Moderate
Complexity
Extensive
Extensive
High
High
Complexity
Must meet or exceed 2 of the 3 items
for a given level
Coding Mr. X’ Outpatient Visit
CPT Code
History
Examination
MDM
Typical Time
99211
N/A
N/A
N/A
5 minutes
99212
Problem
Focused
Problem
Focused
Straightforward
10 minutes
99213
Expanded
Problem
Focused
Expanded
Problem
Focused
Low Complexity 15 minutes
99214
Detailed
Detailed
Moderate
Complexity
25 minutes
99215
Comprehensive
Comprehensive
High
Complexity
40 minutes
For Established Outpatient Office Visits, 2 of 3 components (history, exam,
MDM) must be met or exceeded. For Consultations and New Outpatient Office
Visits, all 3 components must be met. Coding based on time (Counseling or
Coordination of Care) is the exception.
Summary
• E/M Services may be coded by time, BUT
ONLY IF over 50% of the face-to-face part
of the visit involved counseling and
coordination of care.
– Must document in note that over 50% of time
was in counseling and coordination of care
– Must document key points of counseling and/or
coordination of care
If the Service Is NOT Being Coded
by Time:
• Key Components include
– Level of history
– Level of examination
– Complexity of medical decision making
• For established outpatient visits, the highest 2 of
the 3 components define the service rendered.
• For new outpatient visits or outpatitnet
consultations (new or established), all 3
components define the service rendered.
Ms. Z.
Start Time: 9:20am
7/25/08
Duration: 20 minutes
Goal: Ms. Z. will have well managed anxiety 90% of the time.
CC: Ms. Z. presents for f/u of anxiety. She notes “my nerves are bad.”
HPI: Ms. Z. notes a 1 week exacerbation of her anxiety, which she attributes to her son’s military deployment.
She rates anxiety as 9/10 (10=worst) and believes her level of anxiety is out of proportion to event. She also
reports muscular tension, sleep disturbance, and poor concentration. She denies any SI, citing her children as
strong deterrents.
PFSH: Ms. Z. has longstanding GAD. Her meds include sertraline 100mg daily as well as lisinopril 10mg daily
from her PCP. She has family support from her husband, adult daughter, and mother.
ROS:
Constitutional: Ms. Z. reports a reduced appetite but denies any recent weight change
GI: Ms. Z. denies any nausea, vomiting, or diarrhea since starting sertraline
MSE:
Appearance/Behavior: WD WN WF in NAD. Well groomed, good eye contact, cooperative.
Thought/Speech: Denies SI/HI/AH/VH; no overt attention to internal stimuli. Thought processes demonstrate
rumination on son’s deployment. Speech RRR and goal-directed with normal volume, articulation, and initiation.
Mood/Affect: Anxiety 9/10, denies depression, congruent and tearful affect.
Orientation: A&O X 4
Attention span was interrupted by ruminations related to her son and required frequent redirection.
Insight and judgment appear intact, as she recognizes her anxiety and is utilizing her support system.
Imp: Generalized Anxiety Disorder, Severe exacerbation
Plan: We discussed treatment options, including no change, increase in sertraline, or addition of psychotherapy to
target recently increased anxiety. Since she had previously done very well on the current sertraline dose, and since
there is a clear stressor that has triggered her exacerbation, she and I agreed that psychotherapy is the best choice
at present. No change to the sertraline. I will order a referral for psychotherapy. RTC 2 weeks, sooner prn.
Ms. Z.
Start Time: 9:20am
7/25/08
Duration: 20 minutes
Goal: Ms. Z. will have well managed anxiety 90% of the time.
CC: Ms. Z. presents for f/u of anxiety. She notes “my nerves are bad.”
HPI: Ms. Z. notes a 1 week exacerbation of her anxiety, which she attributes to her son’s military deployment.
She rates anxiety as 9/10 (10=worst) and believes her level of anxiety is out of proportion to event. She also
reports muscular tension, sleep disturbance, and poor concentration. She denies any SI, citing her children as
Strong deterrents.
PFSH: Ms. Z. has longstanding GAD. Her meds include sertraline 100mg daily as well as lisinopril 10mg daily
from her PCP. She has family support from her husband, adult daughter, and mother.
ROS:
Constitutional: Ms. Z. reports a reduced appetite but denies any recent weight change
GI: Ms. Z. denies any nausea, vomiting, or diarrhea since starting sertraline
MSE:
Appearance/Behavior: WD WN WF in NAD. Well groomed, good eye contact, cooperative.
Thought/Speech: Denies SI/HI/AH/VH; no overt attention to internal stimuli. Thought processes demonstrate
rumination on son’s deployment. Speech RRR and goal-directed with normal volume, articulation, and initiation.
Mood/Affect: Anxiety 9/10, denies depression, congruent and tearful affect.
Orientation: A&O X 4
Attention span was interrupted by ruminations related to her son and required frequent redirection.
Insight and judgment appear intact, as she recognizes her anxiety and is utilizing her support system.
Imp: Generalized Anxiety Disorder, Severe exacerbation
Plan: We discussed treatment options, including no change, increase in sertraline, or addition of psychotherapy to
target recently increased anxiety. Since she had previously done very well on the current sertraline dose, and since
there is a clear stressor that has triggered her exacerbation, she and I agreed that psychotherapy is the best choice
at present. No change to the sertraline. I will order a referral for psychotherapy. RTC 2 weeks, sooner prn.
Scoring the HPI for Ms. Z.
Level of HPI
Brief
Extended
1997 Guidelines
Chief Complaint
+
1-3 “Elements” or status
of 1-2 chronic conditions*
Chief Complaint
+
4 or more “Elements” or
status of 3 or more
chronic conditions
(*Use of chronic conditions for the 1997 Brief HPI is a KHS interpretation;
other managed care organizations may or may not subscribe to this
Interpretation.)
Review of Systems
Systems Recognized by 1995 and 1997 Guidelines
Constitutional
GI
Psychiatric
Eyes
GU
Endocrine
Ears, Nose, Mouth, Throat
Musculoskeletal
Hematologic/Lymphatic
Cardiovascular
Skin and/or breast
Allergic/Immunologic
Respiratory
Neurological
Level of ROS
Number of Systems Reviewed
None
0
Problem Pertinent
1 system
Extended
2-9 systems
Complete
10 or more systems (or some
systems and a statement all
others negative)
Scoring the PFSH
Level of PFSH
Areas of PFSH for
Areas of PFSH for New
Established Outpatients Outpatients or
New/Established
Consults
None
0
0
Pertinent
1 or more
1 or more
Complete
2 or more
3
Putting the History Together:
Ms. Z
Level of History
HPI
ROS
PFSH
Problem Focused
Brief
None
None
Expanded
Problem Focused
Brief
Problem Pertinent
None
Detailed
Extended
Extended
Pertinent
Comprehensive
Extended
Complete
Complete
1997 Guidelines Psychiatric
Specialty Examination for Ms. Z.
→
→
→
→
→
→
→
→
→
←
Reproduced from the CMS 1997 documentation guidelines:
http://www.cms.hhs.gov/MLNProducts/downloads/master1.pdf
KHS: Scoring Diagnoses and
Treatment Options for Ms. Z.
Self-limiting and/or minor problem, maximum of 2
problems
1 point each
Condition already diagnosed by provider and improved
and/or stable
1 point each
Condition already diagnosed by provider and worsening
2 points each
Condition that is new to the provider without further
work-up planned, maximum of 1 problem
3 points
Condition that is new to the provider and further work-up
is planned
4 points each
Minimal
1 point
Limited
2 points
Multiple
3 points
Extensive
4 points
KHS: Scoring Amount and/or
Complexity of Data for Ms. Z.
Laboratory testing ordered and/or reviewed
1 point
Radiology testing ordered and/or reviewed
1 point
Medical testing ordered and/or reviewed
1 point
Discussion of results with physician who performed or interpreted the
test
1 point
Direct and independent review and interpretation of a specimen,
tracing, or image
1 point
each
Decision to obtain old records and/or collateral information
1 point
Review and written summary of old records and/or collateral
information
2 points
Minimal or none
≤1 point
Limited
2 points
Moderate
3 points
Extensive
≥4 points
→
→
Reproduced from the
CMS 1997
documentation
guidelines:
http://www.cms.hhs.gov/
MLNProducts/downloads
/master1.pdf
Summarizing Medical Decision
Making for Ms. Z
Number of
diagnoses or
management
options
Amount and/or
complexity of
data to be
reviewed
Risk of
complications
and/or
morbidity or
mortality
Type of
decision
making
Minimal
Minimal or none
Minimal
Straightforward
Limited
Limited
Low
Low
Complexity
Multiple
Moderate
Moderate
Moderate
Complexity
Extensive
Extensive
High
High
Complexity
Must meet or exceed 2 of the 3 items
for a given level
Established Outpatient Coding for
Ms. Z.
CPT Code
History
Examination
MDM
Typical Time
99211
N/A
N/A
N/A
5 minutes
99212
Problem
Focused
Problem
Focused
Straightforward
10 minutes
99213
Expanded
Problem
Focused
Expanded
Problem
Focused
Low Complexity 15 minutes
99214
Detailed
Detailed
Moderate
Complexity
25 minutes
99215
Comprehensive
Comprehensive
High
Complexity
40 minutes
For Established Outpatient Office Visits, 2 of 3 components (history, exam,
MDM) must be met or exceeded. For Consultations and New Outpatient Office
Visits, all 3 components must be met. Coding based on time (Counseling or
Coordination of Care) is the exception.
Mr. B.
07/02/09
Start time: 3:15pm
Face-to-face time: 25 minutes
Goal: Mr. B. will be able to manage his daily routine without interruption by hallucinations 95% of the time.
CC: Mr. B. said he was here “to get my prescription refilled.”
HPI: Mr. B. notes his Schizophrenia remains at baseline, with no interval hallucinations or delusions. He indicated he had good
concentration but had difficulty motivating himself to perform hygiene and household chores. He indicated he remained fairly inactive,
spending most of his time inside watching TV. He noted he primarily consumes prepackaged food or inexpensive fast food.
His case manager was present and said it was difficult to interest Mr. B. in activities and that he preferred solitary projects. The case
manager indicated Mr. B. was managing his finances on his own and remembered to refill his prescription on time.
PFSH: Mr. B has a longstanding history of Schizophrenia as well as recent dyslipidemia. He is taking only risperidone 1mg po am
and 2mg po q hs at this time.
ROS:
Constitutional: Intact sleep and energy, stable weight
Musculoskeletal: Denied tremors and dystonia
MSE:
Appearance/Behavior: WD WN BM in NAD. He appeared disheveled with ungroomed hair and beard and disarrayed clothing. He
maintained intermittent eye contact.
Thought/Speech: He denied SI/HI/AH/VH; there was no overt attention to internal stimuli. Speech was RRR with normal volume and
articulation. There was minimal initiation and moderate loosening of associations.
Mood/Affect: He noted a “good” mood and demonstrated a blunted affect.
Orientation: He was A&O X 4
Insight/Judgment: He continues to display limited insight into his negative symptoms but judgment appears intact.
Labs: 6/25/09: Chol 245, LDL 142, HDL 35, Trig 324 (essentially unchanged from 2 months ago)
Impression: Schizophrenia, disorganized type; at baseline
Dyslipidemia
Plan:
Over 50% of the session was spent in Counseling and Coordination of Care. We reviewed option to try a different antipsychotic or different
dose of the current medication to address residual negative symptoms. We reviewed that his current medication could be causing or
worsening his dyslipidemia and that other options might not do this. He expressed understanding and politely declined any change to
medication, so no changes were made. We also discussed his dyslipidemia. We discussed, at length, dietary options that are more hearthealthy than his current diet. We also discussed a walking regimen that might help with weight and lipids. He expressed he would try this
for 3 months, and if not successful, we will need to have him see his PCP about the lipids. RTC 1 month, sooner prn.
Coding Options
• Code by time (Counseling and Coordination
of Care) since this consumed over 50% of
the visit
OR
• Code by History, Exam, and Medical
Decision Making since these are all present
Mr. B.
07/02/09
Start time: 3:15pm
Face-to-face time: 25 minutes
Goal: Mr. B. will be able to manage his daily routine without interruption by hallucinations 95% of the time.
CC: Mr. B. said he was here “to get my prescription refilled.”
HPI: Mr. B. notes his Schizophrenia remains at baseline, with no interval hallucinations or delusions. He indicated he had good
concentration but had difficulty motivating himself to perform hygiene and household chores. He indicated he remained fairly inactive,
spending most of his time inside watching TV. He noted he primarily consumes prepackaged food or inexpensive fast food.
His case manager was present and said it was difficult to interest Mr. B. in activities and that he preferred solitary projects. The case
manager indicated Mr. B. was managing his finances on his own and remembered to refill his prescription on time.
PFSH: Mr. B has a longstanding history of Schizophrenia as well as recent dyslipidemia. He is taking only risperidone 1mg po am
and 2mg po q hs at this time.
ROS:
Constitutional: Intact sleep and energy, stable weight
Musculoskeletal: Denied tremors and dystonia
MSE:
Appearance/Behavior: WD WN BM in NAD. He appeared disheveled with ungroomed hair and beard and disarrayed clothing. He
maintained intermittent eye contact.
Thought/Speech: He denied SI/HI/AH/VH; there was no overt attention to internal stimuli. Speech was RRR with normal volume and
articulation. There was minimal initiation and moderate loosening of associations.
Mood/Affect: He noted a “good” mood and demonstrated a blunted affect.
Orientation: He was A&O X 4
Insight/Judgment: He continues to display limited insight into his negative symptoms but judgment appears intact.
Labs: 6/25/09: Chol 245, LDL 142, HDL 35, Trig 324 (essentially unchanged from 2 months ago)
Impression: Schizophrenia, disorganized type; at baseline
Dyslipidemia
Plan:
Over 50% of the session was spent in Counseling and Coordination of Care. We reviewed option to try a different antipsychotic or different
dose of the current medication to address residual negative symptoms. We reviewed that his current medication could be causing or
worsening his dyslipidemia and that other options might not do this. He expressed understanding and politely declined any change to
medication, so no changes were made. We also discussed his dyslipidemia. We discussed, at length, dietary options that are more hearthealthy than his current diet. We also discussed a walking regimen that might help with weight and lipids. He expressed he would try this
for 3 months, and if not successful, we will need to have him see his PCP about the lipids. RTC 1 month, sooner prn.
Scoring the HPI for Mr. B.
Level of HPI
1997 Guidelines
Brief
Chief Complaint
+
1-3 “Elements” or status
of 1-2 chronic
conditions*
Extended
Chief Complaint
+
4 or more “Elements” or
status of 3 or more
chronic conditions
*(Use of chronic conditions for the 1997 Brief HPI is a KHS interpretation;
other managed care organizations may or may not subscribe to this
Interpretation.)
Review of Systems for Mr. B.
Systems Recognized by 1995 and 1997 Guidelines
Constitutional
GI
Psychiatric
Eyes
GU
Endocrine
Ears, Nose, Mouth, Throat
Musculoskeletal
Hematologic/Lymphatic
Cardiovascular
Skin and/or breast
Allergic/Immunologic
Respiratory
Neurological
Level of ROS
Number of Systems Reviewed
None
0
Problem Pertinent
1 system
Extended
2-9 systems
Complete
10 or more systems (or some
systems and a statement all
others negative)
Scoring the PFSH for Mr. B.
Level of PFSH
Areas of PFSH for
Areas of PFSH for New
Established Outpatients Outpatients or
New/Established
Consults
None
0
0
Pertinent
1 or more
1 or more
Complete
2 or more
3
Putting the History Together:
Mr. B.
Level of History
HPI
ROS
PFSH
Problem Focused
Brief
None
None
Expanded
Problem Focused
Brief
Problem Pertinent
None
Detailed
Extended
Extended
Pertinent
Comprehensive
Extended
Complete
Complete
1997 Guidelines Psychiatric
Specialty Examination for Mr. B.
→
→
→
→
→
→
→
→
Reproduced from the CMS 1997 documentation guidelines:
http://www.cms.hhs.gov/MLNProducts/downloads/master1.pdf
KHS: Scoring Diagnoses and
Treatment Options for Mr. B.
Self-limiting and/or minor problem, maximum of 2
problems
1 point each
Condition already diagnosed by provider and improved
and/or stable
(Schizophrenia, Disorganized, at baseline)
1 point each
Condition already diagnosed by provider and worsening
2 points each
(Uncontrolled dyslipidemia)
Condition that is new to the provider without further
work-up planned, maximum of 1 problem
3 points
Condition that is new to the provider and further work-up
is planned
4 points each
Minimal
1 point
Limited
2 points
Multiple
3 points
Extensive
4 points
(This slide updated 05/04/09)
KHS: Scoring Amount and/or
Complexity of Data for Mr. B.
Laboratory testing ordered and/or reviewed
1 point
Radiology testing ordered and/or reviewed
1 point
Medical testing ordered and/or reviewed
1 point
Discussion of results with physician who performed or interpreted the
test
1 point
Direct and independent review and interpretation of a specimen,
tracing, or image
1 point
each
Decision to obtain old records and/or collateral information
1 point
Review and written summary of old records and/or collateral
information
2 points
Minimal or none
≤1 point
Limited
2 points
Moderate
3 points
Extensive
≥4 points
→
→
Reproduced from the
CMS 1997
documentation
guidelines:
http://www.cms.hhs.gov/
MLNProducts/downloads
/master1.pdf
Summarizing Medical Decision
Making for Mr. B
Number of
diagnoses or
management
options
Amount and/or
complexity of
data to be
reviewed
Risk of
complications
and/or
morbidity or
mortality
Type of
decision
making
Minimal
Minimal or none
Minimal
Straightforward
Limited
Limited
Low
Low
Complexity
Multiple
Moderate
Moderate
Moderate
Complexity
Extensive
Extensive
High
High
Complexity
Must meet or exceed 2 of the 3 items
for a given level
(This slide updated 05/04/09)
Established Outpatient Coding:
Mr. B.
CPT Code
History
Examination
MDM
Typical Time
99211
N/A
N/A
N/A
5 minutes
99212
Problem
Focused
Problem
Focused
Straightforward
10 minutes
99213
Expanded
Problem
Focused
Expanded
Problem
Focused
Low Complexity 15 minutes
99214
Detailed
Detailed
Moderate
Complexity
25 minutes
99215
Comprehensive
Comprehensive
High
Complexity
40 minutes
For Established Outpatient Office Visits, 2 of 3 components (history, exam,
MDM) must be met or exceeded. For Consultations and New Outpatient Office
Visits, all 3 components must be met. Coding based on time (Counseling or
Coordination of Care) is the exception.
What About Coding by Time?
Mr. B.
07/02/09
Start time: 3:15pm
Face-to-face time: 25 minutes
Goal: Mr. B. will be able to manage his daily routine without interruption by hallucinations 95% of the time.
CC: Mr. B. said he was here “to get my prescription refilled.”
HPI: Mr. B. notes his Schizophrenia remains at baseline, with no interval hallucinations or delusions. He indicated he had good
concentration but had difficulty motivating himself to perform hygiene and household chores. He indicated he remained fairly inactive,
spending most of his time inside watching TV. He noted he primarily consumes prepackaged food or inexpensive fast food.
His case manager was present and said it was difficult to interest Mr. B. in activities and that he preferred solitary projects. The case
manager indicated Mr. B. was managing his finances on his own and remembered to refill his prescription on time.
PFSH: Mr. B has a longstanding history of Schizophrenia as well as recent dyslipidemia. He is taking only risperidone 1mg po am
and 2mg po q hs at this time.
ROS:
Constitutional: Intact sleep and energy, stable weight
Musculoskeletal: Denied tremors and dystonia
MSE:
Appearance/Behavior: WD WN BM in NAD. He appeared disheveled with ungroomed hair and beard and disarrayed clothing. He
maintained intermittent eye contact.
Thought/Speech: He denied SI/HI/AH/VH; there was no overt attention to internal stimuli. Speech was RRR with normal volume and
articulation. There was minimal initiation and moderate loosening of associations.
Mood/Affect: He noted a “good” mood and demonstrated a blunted affect.
Orientation: He was A&O X 4
Insight/Judgment: He continues to display limited insight into his negative symptoms but judgment appears intact.
Labs: 6/25/09: Chol 245, LDL 142, HDL 35, Trig 324 (essentially unchanged from 2 months ago)
Impression: Schizophrenia, disorganized type; at baseline
Dyslipidemia
Plan:
Over 50% of the session was spent in Counseling and Coordination of Care. We reviewed option to try a different antipsychotic or different
dose of the current medication to address residual negative symptoms. We reviewed that his current medication could be causing or
worsening his dyslipidemia and that other options might not do this. He expressed understanding and politely declined any change to
medication, so no changes were made. We also discussed his dyslipidemia. We discussed, at length, dietary options that are more hearthealthy than his current diet. We also discussed a walking regimen that might help with weight and lipids. He expressed he would try this
for 3 months, and if not successful, we will need to have him see his PCP about the lipids. RTC 1 month, sooner prn.
Summary:
Established Outpatient Coding
CPT Code
History
Examination
MDM
Typical Time
99211
N/A
N/A
N/A
5 minutes
99212
Problem
Focused
Problem
Focused
Straightforward
10 minutes
99213
Expanded
Problem
Focused
Expanded
Problem
Focused
Low Complexity 15 minutes
99214
Detailed
Detailed
Moderate
Complexity
25 minutes
99215
Comprehensive
Comprehensive
High
Complexity
40 minutes
For Established Outpatient Office Visits, 2 of 3 components (history, exam,
MDM) must be met or exceeded. For Consultations and New Outpatient Office
Visits, all 3 components must be met. Coding based on time (Counseling or
Coordination of Care) is the exception.
Established Outpatient Coding
by Time for Mr. B.
CPT Code
History
Examination
MDM
Typical Time
99211
N/A
N/A
N/A
5 minutes
99212
Problem
Focused
Problem
Focused
Straightforward
10 minutes
99213
Expanded
Problem
Focused
Expanded
Problem
Focused
Low Complexity 15 minutes
99214
Detailed
Detailed
Moderate
Complexity
25 minutes
99215
Comprehensive
Comprehensive
High
Complexity
40 minutes
For Established Outpatient Office Visits, 2 of 3 components (history, exam,
MDM) must be met or exceeded. For Consultations and New Outpatient Office
Visits, all 3 components must be met. Coding based on time (Counseling or
Coordination of Care) is the exception.
Questions?
References
• Current CPT Manual
• CMS Website
– 1995 Guidelines:
http://www.cms.hhs.gov/MLNProducts/downloads/1995dg.
pdf
– 1997 Guidelines:
http://www.cms.hhs.gov/MLNProducts/downloads/master1.
pdf
• HCFA Draft worksheet:
http://www.aafp.org/online/en/home/publications/journals/fpm/
collections/fpmmedicare/meddecisions.html
Blank Scoring Templates
(For an Established Patient
Outpatient Visit, using 1997
guidelines)
Elements of HPI
Location
Quality
Severity
Duration
Timing
Context
Modifying Factors
Associated Signs
and Symptoms
Scoring the HPI
Level of HPI
Brief
Extended
1997 Guidelines
Chief Complaint
+
1-3 “Elements” or status
of 1-2 chronic conditions*
Chief Complaint
+
4 or more “Elements” or
status of 3 or more
chronic conditions
(*Use of chronic conditions for the 1997 Brief HPI is a KHS interpretation;
other managed care organizations may or may not subscribe to this
Interpretation.)
Review of Systems
Systems Recognized by 1995 and 1997 Guidelines
Constitutional
GI
Psychiatric
Eyes
GU
Endocrine
Ears, Nose, Mouth, Throat
Musculoskeletal
Hematologic/Lymphatic
Cardiovascular
Skin and/or breast
Allergic/Immunologic
Respiratory
Neurological
Level of ROS
Number of Systems Reviewed
None
0
Problem Pertinent
1 system
Extended
2-9 systems
Complete
10 or more systems (or some
systems and a statement all
others negative)
Scoring the PFSH
Level of PFSH
Areas of PFSH for
Areas of PFSH for New
Established Outpatients Outpatients or
New/Established
Consults
None
0
0
Pertinent
1 or more
1 or more
Complete
2 or more
3
Putting the History Together
Level of History
HPI
ROS
PFSH
Problem Focused
Brief
None
None
Expanded
Problem Focused
Brief
Problem Pertinent
None
Detailed
Extended
Extended
Pertinent
Comprehensive
Extended
Complete
Complete
1997 Guidelines Psychiatric
Specialty Examination
Reproduced from the CMS 1997 documentation guidelines:
http://www.cms.hhs.gov/MLNProducts/downloads/master1.pdf
KHS: Scoring Diagnoses and
Treatment Options
Self-limiting and/or minor problem, maximum of 2
problems
1 point each
Condition already diagnosed by provider and improved
and/or stable
1 point each
Condition already diagnosed by provider and worsening
2 points each
Condition that is new to the provider without further
work-up planned, maximum of 1 problem
3 points
Condition that is new to the provider and further work-up
is planned
4 points each
Minimal
1 point
Limited
2 points
Multiple
3 points
Extensive
4 points
KHS: Scoring Amount and/or
Complexity of Data
Laboratory testing ordered and/or reviewed
1 point
Radiology testing ordered and/or reviewed
1 point
Medical testing ordered and/or reviewed
1 point
Discussion of results with physician who performed or interpreted the
test
1 point
Direct and independent review and interpretation of a specimen,
tracing, or image
1 point
each
Decision to obtain old records and/or collateral information
1 point
Review and written summary of old records and/or collateral
information
2 points
Minimal or none
≤1 point
Limited
2 points
Moderate
3 points
Extensive
≥4 points
Reproduced from the
CMS 1997
documentation
guidelines:
http://www.cms.hhs.gov/
MLNProducts/downloads
/master1.pdf
Summarizing Medical Decision
Making
Number of
diagnoses or
management
options
Amount and/or
complexity of
data to be
reviewed
Risk of
complications
and/or
morbidity or
mortality
Type of
decision
making
Minimal
Minimal or none
Minimal
Straightforward
Limited
Limited
Low
Low
Complexity
Multiple
Moderate
Moderate
Moderate
Complexity
Extensive
Extensive
High
High
Complexity
Must meet or exceed 2 of the 3 items
for a given level
Established Outpatient Coding
CPT Code
History
Examination
MDM
Typical Time
99211
N/A
N/A
N/A
5 minutes
99212
Problem
Focused
Problem
Focused
Straightforward
10 minutes
99213
Expanded
Problem
Focused
Expanded
Problem
Focused
Low Complexity 15 minutes
99214
Detailed
Detailed
Moderate
Complexity
25 minutes
99215
Comprehensive
Comprehensive
High
Complexity
40 minutes
For Established Outpatient Office Visits, 2 of 3 components (history, exam,
MDM) must be met or exceeded. For Consultations and New Outpatient Office
Visits, all 3 components must be met. Coding based on time (Counseling or
Coordination of Care) is the exception.