E & M CODING
THE LATEST
INTERPRETATION
Ronald Pope, DO
Coding Consultants of NY,LLC
QUICK OVERVIEW
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Choose Level of service for Hx, PE, and
Decision Making
For Established patients pick the middle level
For New patient’s choose the lowest of the
three
Despite the levels on all three sections, you
can never bill higher than your Decision
Making level
HISTORY
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We will not focus on this too much
Key points: For a 99214 you only need a
ROS with 2 different systems
Soc Hx or PMH or FamHx only one item
needed
Refer to the handout for proper Hx coding
PHYSICAL EXAM
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1995 Guidelines
8 Systems = highest level of service
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General
ENT
CV
GU
Musculoskeletal
Lymph
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Eyes
Resp
GI
Derm
Psych
Neuro
MEDICAL DECISION MAKING
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3 Components, each coded separately
Take the middle level of service
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Diagnosis
Data
Risk
DIAGNOSIS
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Based upon a point system
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4 points = High Complexity (99215)
3 points = Moderate Complexity (99214)
2 points = Low Complexity (99213)
1 point = Straightforward (99212)
There are two separate ways to calculate the
points
DIAGNOSIS-METHOD I
(NUMBER OF DX)
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1 Point: for each new or established problem for which the
diagnosis and/or treatment plan is evident with or without
diagnostic confirmation
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1 Point: Each new or established problem for which the
diagnosis and/or treatment plan is not evident. Must be a
plausible differential diagnoses, comorbidities or
complications (not counted as separate problems) clearly
stated and supported by information in record: requiring
diagnostic evaluation or confirmation
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In other words: Each problem or Diff Dx gets a point, but
must be addressed in the plan as workup and/or Tx
DIAGNOSIS METHOD II
(TREATMENT OPTIONS)
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The entries are examples of commonly prescribed
treatments and the point values are illustrative of
their intended quantifications. Many other treatments
exist and should be counted when documented.
Do not count as treatment option’s notations
such as: Continue “same” therapy or “no
change” in therapy (including drug management)
if specified therapy is not described (record does
not document what the current therapy is nor
that the physician reviewed it).
DIAGNOSIS METHOD II
(TREATMENT OPTIONS)
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EACH OF THESE = 1 Point unless specified
otherwise
Drug management, per problem.
– <3 new or current meds/problem = 1 Point
– > 3 new or current meds/problem =2 Points
Open or percutaneous therapeutic cardiac, surgical
or radiological procedure; minor or major
Physical, occupational or speech therapy or other
manipulation
Closed treatment for fracture or dislocation
DIAGNOSIS METHOD II
(TREATMENT OPTIONS)
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EACH OF THESE = 1 Point unless specified
otherwise
IV fluid or fluid component replacement, or establish
IV access when record is clear that such involved
physician decision-making and was not standard
facility “protocol”
Complex insulin prescription (SC or combo of
SC/IV), hyperalimentation, insulin drip or other
complex IV admix prescription = 2 Points
DIAGNOSIS METHOD II
(TREATMENT OPTIONS)
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EACH OF THESE = 1 Point unless specified
otherwise
Conservative measures such as rest, ice/heat,
specific diet, etc.
Radiation therapy
Joint, body cavity, soft tissue, etc injection /
aspiration
Patient education regarding self or home care
Decision to admit to hospital
Discuss case with other physician
DIAGNOSIS METHOD II
(TREATMENT OPTIONS)
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Patient has 2 chronic problems, Diabetes
and COPD and The case is discussed with
the Pulmonologist. This is 3 points or a
99214
If you decide to admit the patient to the
hospital it add one more point and is a 99215
An Alternative 99215 would be if the DM,
COPD patient was sent to the hospital to R/O
Pneumonia vs CHF
DATA
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Categories:
– Labs
– Imaging
– Procedures
– Discuss case with performing physician,
– True referral, Phone or otherwise (Seeking opinion or
advice from another provider)
– Review old records w/o summarizing
– Review old records and summarize (2 Points)
– Independent visualization and interpretation of an image,
EKG or laboratory specimen not reported for separate payment.
(each image is 1 point)
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Review of significant physiologic monitoring or testing data
not reported for separate payment
DATA
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Categories:
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Labs (Review or Order labs) – Each panel counts as 1. Example
TSH, Free T4 =2 labs, while CBC counts as 1.
 1-3 Labs = 1 Point……………4 or more = 2 Points
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Imaging Labs (Review or Order Imaging) – Each CPT code
counts as 1 item. Example CT Abd & Pelvis = 2 items
 1-3 imaging = 1 Point…………4 or more = 2 Points
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Procedures (Review or Order Procedures – Each CPT code
counts as 1 item. Example Colposcopy & Endometrial Biopsy = 2
items
 1-3 procedures = 1 Point….....4 or more = 2 Points
RISK
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Divided into 3 types for ease of navigating
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Presenting problem
Diagnostic procedures ordered
Management options selected
Each of the 3 types are broken into levels of
complexity (ie. Level of service)
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Minimal
Low
Moderate
High
RISK
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Refer to the Handout
Notable items:
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If you write a prescription drug or refill it as the
patient is stable, this is a 99214 by risk
If you have a chronic problem that severely
worsened (ie. HgbA1C goes from 7  11) you
have a 99215 based upon risk
If it is worsened but not severely you have a
99214 based upon risk
QUICK CODE 99213
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2 problems in A/P
2 Systems examined
– Ie. DM, COPD and NAD, Nml Resp Effort
– Remember you must have a plan to go with the DM ,COPD
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That’s all you need !!!!
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Alternative: 1 Chronic Problem Stable and you continue four
or more medications for the problem. (ie. HTN, continue ACE,
B-Blocker, HCTZ, and Ca Channel Blocker)
QUICK CODE 99214
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8 System Physical Exam
3 Problems with a plan
1 or more Medications renewed or
prescribed
QUESTIONS ?