Evaluation and Management Coding
The Evaluation and Management (E/M) section of the CPT book contains codes for office and outpatient
setting, custodial care, hospital medical services, consultation, emergency department, critical care, preventive
medicine, and others.
There are 3 key components which are used to help determine the appropriate level of service:
 HISTORY relative to the patient’s clinical background
 EXAM covering the present and / or concurrent problems
 MEDICAL DECISION MAKING performed by the physician to manage the patient’s health problems
There are 4 ELEMENTS:
 COUNSELING with the patient and / or family members
 COORDINATION of CARE with any other physicians, facilities, and / or health care bureau’s
 NATURE of patient’s problem
 TIME is considered the controlling factor in selecting the E/M level of service only when more than
50% of the face-to-face time is spent on counseling and/or coordination of care.
The level of the Evaluation and Management (E/M) Service chosen depends upon whether the patient is a new
or established patient. A new patient requires 3 of the 3 key components to be met where an established patient
only requires 2 of the 3 key components to be met.
When a physician selects an E/M level of service they must:







Identify where and what services were performed
Identify who received the service
Review the E/M level of service descriptors
Determine the history obtained
Determine the exam performed
Determine the level of complexity in the decision making
Determine if the patient is a NEW or ESTABLISHED patient
New patient vs. Established patient
A new patient is one who has not received any professional services from the physician, or another physician of
the same specialty who belongs to the same group practice, within the past 3 years.
An established patient is one who has received professional services from the physician, or another physician of
the same specialty who belongs to the same group practice, within the past 3 years.
2
History
To select the overall level of history there are four components within the history itself to
evaluate:
 Chief Complaint
 History of Present Illness
 Review of Systems
 Past, Family and Social History
History of Present Illness (HPI)
The HPI is a chronological description that uses eight elements to identify the patient’s present
illness, signs and/or symptoms from the first onset to present. The eight elements include:
 Location – where the symptom or problem is occurring (e.g., RUQ abdominal pain, right
knee pain)
 Quality – a description of the symptom or pain (e.g., sharp, dull, burning)
 Severity – a rating or description of severity of the symptom or pain
(e.g., mild, scale of 1-10)
 Duration – how long a pain or symptom lasts or has been present or persisted (e.g., one
week, since yesterday)
 Timing – when does a symptom or pain occur (e.g., after eating, in the morning or after a
workout)
 Context – describes the situation surrounding the problem, episode or condition, can be
stated in terms of the “big picture” (e.g., such as an injured ankle while playing
basketball)
 Modifying Factors – what makes symptom or pain better or worse
(e.g., taking meds, ice, heating pad)
 Associated Signs and Symptoms – additional problems associated with the specific
symptoms the patient presents for. This information may help in identifying a new
disease process or underlying problems related to the existing problem (e.g., migraine
with aura and nausea)
3
Review of Systems (ROS)
A series of positive or negative responses to questions asked by the practitioner. The review of
systems does not include physical exam elements.
 Constitutional – high fever, weight loss/gain, fatigue
 Eyes – diplopia, blurred vision, strain or pain
 ENT – discharge or bleeding from nose, difficulty swallowing
 Cardiovascular – edema, chest pain, syncope, palpitations
 Respiratory – shortness of breath, cough
 Gastrointestinal – bloating, last bowel movement
 Genitourinary – frequency, burning or pain, hematuria
 Skin – rashes, itching
 Neurological – headaches, seizures
 Psychological – insomnia, attitude
 Endocrine – excessive hunger or thirst
 Hematologic/Lymphatic – anemia, bruising or bleeding problems
 Musculoskeletal – joint swelling, stiffness
 Allergic – allergy symptoms or reactions
 All others negative - The systems with positive or pertinent negative responses must be
individually documented. For the remaining systems, a notation including “all other
systems negative” is permitted.
The provider must have actually reviewed the remaining systems and had negative
responses for the above to be applicable.
4
Exam
Systems
Body Areas
Constitutional
Head
Eye
Neck
ENT
Chest
CVS
Abdomen
Respiratory
Genital/Buttocks
Allergic
Back
GI
Extremity
GU
Skin
Neurological
Psychiatric
Endocrine
Hematologic/Lymphatic
Musculoskeletal
5
6
Medical Decision Making (MDM)
Medical decision making is considered the thought process of the physician.
There are four levels of medical decision making:




Straightforward
Low Complexity
Moderate Complexity
High Complexity
To qualify for a given type of medical decision making, the following three elements are considered:



The number of diagnoses or management options.
The amount and/or complexity of the data, diagnostic tests, and/or other information that must be
obtained and reviewed.
The risk of significant complications, morbidity, and/or mortality as well as comorbidities
associated with the presenting problem(s), diagnostic procedure(s), and/or possible management
options.
Number of diagnoses and management options
The number of diagnoses or management options is defined as:
PROBLEM
Self-limited, minor (stable,
improved or worsening)
Est problem (to practitioner)
stable, improved
Est problem (to practitioner)
worsening
New problem (to practitioner)
no additional work-up
New problem (to practitioner)
Additional work-up planned
NUMBER
(Max = 2)
POINTS
1
1
2
(Max = 1)
3
4
7
Complexity of Data
The complexity of data is a determining factor in your medical decision making.
Data consists of:
TYPE OF DATA
POINTS
Review and/or order clinical lab tests
Review and/or order tests in radiology section of CPT (70010-79999)
Review and/or order tests in medicine section of CPT (90281-99602)
Discuss test results with performing MD
Independent review of image, tracing, or specimen
Decision to obtain olds records and/or obtain History from others
Review/summarize old records, and/or obtain History
1
1
1
1
2
1
2
The data does not get a cumulative total per line. In other words, no matter how many lab results you order or
review, you only get 1 point. However, you do get a cumulative total score for the section.
Risk
The assessment of risk is based on the risk related to the presenting problem and to the disease process
anticipated between the present encounter and the next one.
The four types of risk are:




Minimal
Low
Moderate
High
The highest level of risk in any one category determines the overall level of risk.
8
PROVIDER
PATIENT
AUDITOR
Date of Service
Pre-Audit CPT Code(s)
Date of Audit
Post-Audit CPT Code(s)
Pre-Audit Diagnosis Code(s)
Post-Audit Diagnosis Code(s)
3 of 3 Required
HISTORY
H
P
I
R
O
S
Severity
Timing
Modifying Factors
Location
Quality
Context
Associated Signs & Sx
Constitutional
Skin
Eyes
Allergy/Immunology
GU
CV
Respiratory
Endo
Neuro
Musculo-skeletal
Heme/Lymph
Psych
“All others negative”
ENMT
GI
Exp. Problem
Focused
Detailed
Comprehensive
Brief
(1-3)
Brief
(1-3)
Extended
(4 or more)
Extended
(4 or more)
None
Pertinent to Problem
Extended
(1 system)
(2-9 systems)
Complete
(10 or more systems or some
systems with statement “all
others negative”)
None
Pertinent
Complete
(1 history area)
(New Pt-3 history areas
Est Pt-2 of 3 areas
Past History (Patient’s past experience with illness, surgery, injury and treatments)
P
F
S
H
Family History ( a review of medical events in the patient’s family including diseases
which may be hereditary and/or place patient at risk)
None
Body Aeas
Social History (an age-appropriate review of past and current activities)
Head incl face
Chest incl breast & axilla
Constitutional
(e.g. VS gen app)
Ears, nose,
mouth, throat
CV
Eyes
Back incl spine
Problem Focused
Exp Problem
Focused
Detailed
Comprehensive
1 area or system
2 to 4 areas
or systems
5 to 7 areas
or systems
8 or more systems
Each extremity
Resp
Musc/skel
Psych
GI
Skin
GU
Neuro
Heme
Lymph
Immun
Number of Diagnoses or
Management Options Selected
“PROBLEMS”
Box A
Abdomen
Genitalia incl groin & back
Neck
Organ Sys.
Exam
Duration
Problem
Focused
Problems
Number
Points
Self-limited or minor (stable, improved or worsening
Established problem (to practitioner) stable, improved
Established problem (to practitioner) worsening
New problem (to practitioner),
no additional work-up planned
New problem (to practitioner),
additional work-up planned
Max = 2
1
1
2
Max = 1
Box C
Presenting
Problem(s)
Results
M
I
N
I
M
A
L
3
4
Bring total to line “A” in BOX D
*One self-limited or minor problem
e.g., cold, insect bite, tinea
corporis
*Two or more self-limited or minor
problems
“DATA”
Box B
Amount and/or Complexity
of the Data to be Reviewed
Points
Review and/or order clinical lab tests
Review and/or order tests in the Radiology section of CPT
Review and/or order tests from the Medicine section of CPT
Discussion of test results with performing physician
Decision to obtain old records, and/or
decision to obtain history from someone other than the patient
1
1
1
1
L
O
W
(2)
*Acute uncomplicated illness or
injury, e.g., cystitis, allergic
rhinitis, simple sprain
1
Review and summation of old records, and/or
obtaining history from someone other than the patient and/or
discussion of the case with another HCP
2
Independent visualization of image, tracing or specimen itself
(not simply review of report)
2
Bring total to line “B” in BOX D
M
O
D
E
R
A
T
E
(3)
BOX D The highest level reached by 2 Boxes determines the ultimate
Medical Decision Making
Final Result of Complexity
of Medical Decision Making
Box D
A
PROBLEM(S)
B
DATA
C
2 of 3 required
1
Minimal
2
Limited
3
Multiple
4
Extensive
1
Minimal
2
Limited
3
Moderate
4
Extensive
High
High
RISK
Minimal
Low
(3)
Moderate
Type of
Medical Decision Making
Straightforward
LOW
Moderate
Created by Lisa Sowers 8/8/06
*One stable chronic illness, e.g.,
well-controlled hypertension or
non-insulin dependent diabetes,
cataracts, BPH
H
I
G
H
“RISK”
Diagnostic Procedure(s)
Ordered
*Lab tests requiring
venipuncture
*Chest X-rays
*EKG/EEG
*Urinalysis
*Ultrasound
*Physiologic tests not
under stress, e.g., PFT
*Non-cardiovascular
imaging studies with
contrast e.g., barium
enema
*Superficial needle
biopsy
*Clinical laboratory tests
requiring arterial
puncture
Risk of Complication
and/or Morbidity or Mortality
Management Options
Selected
*Rest
*Gargles
*Elastic bandages
*Superficial dressings
*OTC drugs
*Minor surgery with no
identified risk factors
*Physical therapy
*Occupational therapy
*IV fluids without additives
*One or more chronic illnesses
with mild exacerbation,
progression or side effects of
treatment
*Two or more stable chronic
illnesses
*Undiagnosed new problem with
uncertain prognosis
*Acute illness with systemic
symptom(s) e.g., pneumonitis,
colitis
*Acute complicated injury, e.g.,
Head injury with brief loss of
consciousness
*Physiologic test under
stress e.g., stress echo
*Minor surgery with identified
risk factors
*Diagnostic endoscopy with
no identified risk factors
*Elective major surgery
(open, percutaneous, or
endoscopic) with no
identified risk factors
*One or more chronic illnesses
with severe exacerbation,
progression, or side effects of
treatment
* Cardiovascular imaging
study with contrast with
identified risk factors
*Acute or chronic illnesses or
injuries that may pose a threat to
life or bodily functions e.g., acute
MI, severe respiratory distress
(4)
*Abrupt change in neurologic
status, e.g., seizure, TIA,
weakness or sensory loss
*Cardiovascular imaging
studies with contrast and
no identified risk factors,
e.g., cardiac cath
*Rx drug management
*IV fluids with additives
*Obtain fluid from body
cavity e.g., lumbar
puncture, joint aspiration
*Cardiac electrophysiologic
test
*Diagnostic endoscopies
with identified risk
factors
*Discography
*Closed treatment of fracture or
dislocation w/o manipulation
*Elective major surgery (open,
percutaneous, or endoscopic)
with idenified risk factors
*Emergency major surgery
(open, percutaneous, or
endoscopic
*Parenteral controlled
substances
*Drug therapy requiring
intensive monitoring for toxicity
*Decision to DNR or decrease
care because of poor
prognosis
The highest level of risk in any one category determines the overall level of risk. Move highest level
reached to line “C” in Box D.
O
U
T
P
A
T
I
E
N
T
S
E
R
V
I
C
E
S
OFFICE / OUTPATIENT VISIT, NEW PATIENT
E & M CODE
HISTORY
EXAM
99201
F
F
99202
99203
99204
99205
E
D
C
C
E
D
C
C
MDM
S
S
L
M
H
OFFICE / OUTPATIENT VISIT, ESTABLISHED PATIENT
E & M CODE
99211
99212
99213
99214
99215
HISTORY
N/A
F
E
D
C
EXAM
N/A
F
E
D
C
OFFICE / CONSULT, NEW OR ESTABLISHED PATIENT
E & M CODE
HISTORY
EXAM
99241
F
F
99242
E
E
99243
D
D
99244
99245
C
C
3 of 3 REQUIRED
AVG. TIME
10
C
C
20
30
45
60
2 of 3 REQUIRED
MDM
N/A
S
L
M
H
MDM
S
S
L
AVG. TIME
5
10
15
25
40
3 of 3 REQUIRED
AVG. TIME
15
30
40
M
H
60
80
ADDITIONAL AUDIT CRITERIA
Y
N
N/A
Patient’s name & identifiers on documentation?
Documentation found for date of service?
Note / Consult signed and dated?
Chief Complaint/reason for visit documented?
Medical record legible and complete?
All documented services billed?
Appropriate use of modifiers?
Time documented for time-based services?
Diagnosis sequencing correct?
Resident involved with service?
PCE / Teaching Physician rules followed?
ABN form completed as appropriate?
Chief Complaint
Required
HPI Elements:
Lisa the qualifying statements:
1 - 3 = Brief
4 + = Extended
Review of Systems:
List the qualifying statements
1 = Problem pertinent
2 - 9 = Extended
10 + = Complete
Constitutional Symptoms
Eyes
Location
Ears, Nose, Throat, Mouth
Quality
Cardiovascular
Severity
Respiratory
Duration
Gastrointestinal
Timing
Genitourinary
Context
Musculoskeletal
Modifying Factors
Associated Signs and
symptoms
Integumentary (Skin and/
or breast)
Neurological
Psychiatric
LOCATION/SITE
Endocrine
DOCUMENTATION SOURCE
Hematologic/Lymphatic
SPECIALTY
Allergic/Immunlogic
COMMENTS:
10
Created by Lisa Sowers 8/8/06
Medical Decision Making
Number of Diagnoses or
Management Options Selected
“PROBLEMS”
Box A
Problems
Self-limited or minor (stable, improved or worsening
Established problem (to practitioner) stable, improved
Established problem (to practitioner) worsening
New problem (to practitioner),
no additional work-up planned
New problem (to practitioner),
additional work-up planned
Number
Max = 2
Points
1
1
Presenting
Problem(s)
Results
M
I
N
I
M
A
L
2
Max = 1
Box C
3
4
Bring total to line “A” in BOX D
*One self-limited or minor problem
e.g., cold, insect bite, tinea
corporis
*Two or more self-limited or minor
problems
Points
L
O
W
Review and/or order clinical lab tests
Review and/or order tests in the Radiology section of CPT
Review and/or order tests from the Medicine section of CPT
1
1
1
(2)
Discussion of test results with performing physician
Decision to obtain old records, and/or
decision to obtain history from someone other than the patient
1
Amount and/or Complexity
of the Data to be Reviewed
“DATA”
Box B
*Acute uncomplicated illness or
injury, e.g., cystitis, allergic
rhinitis, simple sprain
1
Review and summation of old records, and/or
obtaining history from someone other than the patient and/or
discussion of the case with another HCP
2
Independent visualization of image, tracing or specimen itself
(not simply review of report)
2
Bring total to line “B” in BOX D
M
O
D
E
R
A
T
E
(3)
BOX D The highest level reached by 2 Boxes determines the ultimate
Medical Decision Making
Final Result of Complexity
of Medical Decision Making
Box D
A
B
C
PROBLEM(S)
DATA
1
Minimal
1
Minimal
2 of 3 required
3
Multiple
2
Limited
3
Moderate
High
High
RISK
Minimal
Low
(3)
Moderate
Type of
Medical Decision Making
Straightforward
LOW
Moderate
Created by Lisa Sowers 8/8/06
 4
Extensive
2
Limited
 4
*One stable chronic illness, e.g.,
well-controlled hypertension or
non-insulin dependent diabetes,
cataracts, BPH
H
I
G
H
Extensive
“RISK”
Diagnostic Procedure(s)
Ordered
*Lab tests requiring
venipuncture
*Chest X-rays
*EKG/EEG
*Urinalysis
*Ultrasound
*Physiologic tests not
under stress, e.g., PFT
*Non-cardiovascular
imaging studies with
contrast e.g., barium
enema
*Superficial needle
biopsy
*Clinical laboratory tests
requiring arterial
puncture
Risk of Complication
and/or Morbidity or Mortality
Management Options
Selected
*Rest
*Gargles
*Elastic bandages
*Superficial dressings
*OTC drugs
*Minor surgery with no
identified risk factors
*Physical therapy
*Occupational therapy
*IV fluids without additives
*One or more chronic illnesses
with mild exacerbation,
progression or side effects of
treatment
*Two or more stable chronic
illnesses
*Undiagnosed new problem with
uncertain prognosis
*Acute illness with systemic
symptom(s) e.g., pneumonitis,
colitis
*Acute complicated injury, e.g.,
Head injury with brief loss of
consciousness
*Physiologic test under
stress e.g., stress echo
*Minor surgery with identified
risk factors
*Diagnostic endoscopy with
no identified risk factors
*Elective major surgery
(open, percutaneous, or
endoscopic) with no
identified risk factors
*One or more chronic illnesses
with severe exacerbation,
progression, or side effects of
treatment
* Cardiovascular imaging
study with contrast with
identified risk factors
*Acute or chronic illnesses or
injuries that may pose a threat to
life or bodily functions e.g., acute
MI, severe respiratory distress
(4)
*Abrupt change in neurologic
status, e.g., seizure, TIA,
weakness or sensory loss
*Cardiovascular imaging
studies with contrast and
no identified risk factors,
e.g., cardiac cath
*Rx drug management
*IV fluids with additives
*Obtain fluid from body
cavity e.g., lumbar
puncture, joint aspiration
*Cardiac electrophysiologic
test
*Diagnostic endoscopies
with identified risk
factors
*Discography
*Closed treatment of fracture or
dislocation w/o manipulation
*Elective major surgery (open,
percutaneous, or endoscopic)
with idenified risk factors
*Emergency major surgery
(open, percutaneous, or
endoscopic
*Parenteral controlled
substances
*Drug therapy requiring
intensive monitoring for toxicity
*Decision to DNR or decrease
care because of poor
prognosis
The highest level of risk in any one category determines the overall level of risk. Move highest level
reached to line “C” in Box D.
11
Box A “Problems”
Box A
“PROBLEMS”
Problems
Self-limited or minor (stable, improved or
worsening
Number of Diagnoses or
Management Options Selected
Number
Points
Max = 2
1
Established problem (to practitioner) stable,
improved
1
Established problem (to practitioner)
worsening
2
New problem (to practitioner),
no additional work-up planned
New problem (to practitioner),
additional work-up planned
Max = 1
Results
3
4
Bring total to line “A” in BOX D
A chronic or established problem is considered to
be new (to practitioner) if they have not previously
treated the problem.
Each type of problem addressed during the visit is
assigned a point value.
Self limited/Minor problems and New problems have
a maximum point value that can be accumulated.
Box A points are cumulative per line. The total point
value assigned to Box A is the sum of all cumulative
points per line.
Box B “Data”
Box B
“DATA”
Amount and/or Complexity
of the Data to be Reviewed
Points
Review and/or order clinical lab tests
1
Review and/or order tests in the Radiology section of CPT
1
Review and/or order tests from the Medicine section of CPT
1
Discussion of test results with performing physician
1
Decision to obtain old records, and/or
decision to obtain history from someone other than the patient
1
Review and summation of old records, and/or
obtaining history from someone other than the patient and/or
discussion of the case with another HCP
2
Independent visualization of image, tracing or specimen itself
(not simply review of report)
2
Bring total to line “B” in BOX D
The data box does not get a cumulative total per
line. In other words, no matter how many lab results
you order or review, you only get one point.
However, you do get a cumulative total score for the
box
13
Box C “Risk”
Box C
Presenting
Problem(s)
M
I
N
I
M
A
L
*One self-limited or minor problem
e.g., cold, insect bite, tinea
corporis
*Two or more self-limited or minor
problems
L
O
W
*One stable chronic illness, e.g.,
well-controlled hypertension or
non-insulin dependent diabetes,
cataracts, BPH
(2)
*Acute uncomplicated illness or
injury, e.g., cystitis, allergic
rhinitis, simple sprain
M
O
D
E
R
A
T
E
(3)
H
I
G
H
“RISK”
Diagnostic Procedure(s)
Ordered
*Lab tests requiring
venipuncture
*Chest X-rays
*EKG/EEG
*Urinalysis
*Ultrasound
*Physiologic tests not
under stress, e.g., PFT
*Non-cardiovascular
imaging studies with
contrast e.g., barium
enema
*Superficial needle
biopsy
*Clinical laboratory tests
requiring arterial
puncture
Risk of Complication
and/or Morbidity or Mortality
Management Options
Selected
*Rest
*Gargles
*Elastic bandages
*Superficial dressings
*OTC drugs
*Minor surgery with no
identified risk factors
*Physical therapy
*Occupational therapy
*IV fluids without additives
*One or more chronic illnesses
with mild exacerbation,
progression or side effects of
treatment
*Two or more stable chronic
illnesses
*Undiagnosed new problem with
uncertain prognosis
*Acute illness with systemic
symptom(s) e.g., pneumonitis,
colitis
*Acute complicated injury, e.g.,
Head injury with brief loss of
consciousness
*Physiologic test under
stress e.g., stress echo
*Minor surgery with identified
risk factors
*Diagnostic endoscopy with
no identified risk factors
*Elective major surgery
(open, percutaneous, or
endoscopic) with no
identified risk factors
*One or more chronic illnesses
with severe exacerbation,
progression, or side effects of
treatment
* Cardiovascular imaging
study with contrast with
identified risk factors
*Acute or chronic illnesses or
injuries that may pose a threat to
life or bodily functions e.g., acute
MI, severe respiratory distress
(4)
*Abrupt change in neurologic
status, e.g., seizure, TIA,
weakness or sensory loss
*Cardiovascular imaging
studies with contrast and
no identified risk factors,
e.g., cardiac cath
*Rx drug management
*IV fluids with additives
*Obtain fluid from body
cavity e.g., lumbar
puncture, joint aspiration
*Cardiac electrophysiologic
test
*Diagnostic endoscopies
with identified risk
factors
*Discography
*Closed treatment of fracture or
dislocation w/o manipulation
*Elective major surgery (open,
percutaneous, or endoscopic)
with idenified risk factors
*Emergency major surgery
(open, percutaneous, or
endoscopic
*Parenteral controlled
substances
*Drug therapy requiring
intensive monitoring for toxicity
*Decision to DNR or decrease
care because of poor
prognosis
The highest level of risk in any one category determines the overall level of risk. Move highest level
reached to line “C” in Box D.
The assessment of risk is based on the risk
related to the presenting problem and to the
disease process anticipated between the
present encounter and the next one.
When prescribing OTC meds above the normal
manufacture directions for usage, it is
considered Rx drug management due to the
increased risk.
14
Box D Final Result of
Complexity of MDM
BOX D The highest level reached by 2 Boxes determines the ultimate
Medical Decision Making
Final Result of Complexity
of Medical Decision Making
Box D
2 of 3 required
A
PROBLEM(S)
1
Minimal
2
Limited
3
Multiple
4
Extensive
B
DATA
1
Minimal
2
Limited
3
Moderate
4
Extensive
C
RISK
Minimal
Low
(3)
Moderate
High
Type of
Medical Decision Making
Straightforward
LOW
Moderate
High
The medical decision making level is
determined in this box.
The cumulative totals from Box A and B are
transferred to this box.
The highest level of risk in Box C is transferred to
this box.
The overall level of medical decision making is
determined by the highest level reached by two
boxes.
15
Example
Moderate Problem
(99214)
Number of Diagnoses or
Management Options Selected
“PROBLEMS”
Box A
Problems
Self-limited or minor (stable, improved or
worsening
Established problem (to practitioner) stable,
improved
Number
Points
Max = 2
1
1,1,1
1
Established problem (to practitioner)
worsening
Results
3
2
New problem (to practitioner),
no additional work-up planned
Max = 1
New problem (to practitioner),
additional work-up planned
3
4
Bring total to line “A” in BOX D
A
PROBLEM(S)
3
1
Minimal
2
Limited
3
Multiple
4
Extensive
99212 / 99201
& 99202
99213 / 99203
99214 / 99204
99215 / 99205
The cumulative total from Box A is transferred to
line A (Problems) of Box D.
16
Example
Minimal Data
(99212)
Amount and/or
Complexity
of the Data to be
Reviewed
“DATA”
Box B
Points
Review and/or order clinical lab tests
1
Review and/or order tests in the Radiology section of CPT
1
Review and/or order tests from the Medicine section of CPT
1
Discussion of test results with performing physician
1
Decision to obtain old records, and/or
decision to obtain history from someone other than the patient
1
Review and summation of old records, and/or
obtaining history from someone other than the patient and/or
discussion of the case with another HCP
2
Independent visualization of image, tracing or specimen itself
(not simply review of report)
2
Bring total to line “B” in BOX D
B
DATA
1
1
Minimal
2
Limited
3
Moderate
4
Extensive
99212 / 99201
& 99202
99213 / 99203
99214 / 99204
99215 / 99205
The cumulative total from Box B is transferred to
line B (Data) of Box D.
17
Example
Moderate Risk
(99214)
Presenting
Problem(s)
M
I
N
I
M
A
L
Diagnostic Procedure(s)
Ordered
*One self-limited or minor problem
e.g., cold, insect bite, tinea
corporis
*Two or more self-limited or minor
problems
L
O
W
*One stable chronic illness, e.g.,
well-controlled hypertension or
non-insulin dependent diabetes,
cataracts, BPH
(2)
*Acute uncomplicated illness or
injury, e.g., cystitis, allergic
rhinitis, simple sprain
M
O
D
E
R
A
T
E
(3)
H
I
G
H
Risk of Complication
and/or Morbidity or Mortality
“RISK”
Box C
requiring
*Lab*Lab
teststest
requiring
venipuncture
venipuncture
*Chest X-rays
*EKG/EEG
*Urinalysis
*Ultrasound
*Physiologic tests not
under stress, e.g., PFT
*Non-cardiovascular
imaging studies with
contrast e.g., barium
enema
*Superficial needle
biopsy
*Clinical laboratory tests
requiring arterial
puncture
Management Options
Selected
*Rest
*Gargles
*Elastic bandages
*Superficial dressings
*OTC drugs
*Minor surgery with no
identified risk factors
*Physical therapy
*Occupational therapy
*IV fluids without additives
*One or more chronic illnesses
with mild exacerbation,
progression or side effects of
treatment
*Two
or more
stable
*Two
or more
stable
chronic
chronic illnesses
illnesses
*Undiagnosed new problem with
uncertain prognosis
*Acute illness with systemic
symptom(s) e.g., pneumonitis,
colitis
*Acute complicated injury, e.g.,
Head injury with brief loss of
consciousness
*Physiologic test under
stress e.g., stress echo
*Minor surgery with identified
risk factors
*Diagnostic endoscopy with
no identified risk factors
*Elective major surgery
(open, percutaneous, or
endoscopic) with no
identified risk factors
*One or more chronic illnesses
with severe exacerbation,
progression, or side effects of
treatment
* Cardiovascular imaging
study with contrast with
identified risk factors
*Cardiovascular imaging
studies with contrast and
no identified risk factors,
e.g., cardiac cath
*IV fluids with additives
*Obtain fluid from body
cavity e.g., lumbar
puncture, joint aspiration
*Acute or chronic illnesses or
injuries that may pose a threat to
life or bodily functions e.g., acute
MI, severe respiratory distress
(4)
*Abrupt change in neurologic
status, e.g., seizure, TIA,
weakness or sensory loss
drug
management
*RxRX
drug
management
*Cardiac electrophysiologic
test
*Diagnostic endoscopies
with identified risk
factors
*Discography
*Closed treatment of fracture or
dislocation w/o manipulation
*Elective major surgery (open,
percutaneous, or endoscopic)
with idenified risk factors
*Emergency major surgery
(open, percutaneous, or
endoscopic
*Parenteral controlled
substances
*Drug therapy requiring
intensive monitoring for toxicity
*Decision to DNR or decrease
care because of poor
prognosis
The highest level of risk in any one category determines the overall level of risk. Move highest level
reached to line “C” in Box D.
C
RISK
Minimal
Low
(3)
Moderate
High
99212 / 99201
& 99202
99213 / 99203
99214 / 99204
99215 / 99205
The highest level of risk in Box C is transferred to
line C (Risk) of Box D.
18
Example
Moderate MDM
(99214)
BOX D The highest level reached by 2 Boxes determines the ultimate
Medical Decision Making
Final Result of Complexity
of Medical Decision Making
Box D
2 of 3 required
A
PROBLEM(S)
1
Minimal
2
Limited
3
Multiple
4
Extensive
B
DATA
1
Minimal
2
Limited
3
Moderate
4
Extensive
C
RISK
Minimal
Low
(3)
Moderate
High
Type of
Medical Decision Making
Straightforward
LOW
Moderate
High
99212 / 99201
& 99202
99213 / 99203
99214 / 99204
99215 / 99205
This is how Box D should look after bringing the
information forward from the other boxes.
To determine the overall level of Medical Decision
Making, drop off the lowest box circled. The level
of MDM is then determined by the location of the
next box circled. A point to remember when
selecting the level of MDM is that two boxes must
meet or exceed the same level to qualify for that
level.
19
Example
Moderate MDM
(99214)
BOX D The highest level reached by 2 Boxes determines the ultimate
Medical Decision Making
Final Result of Complexity
of Medical Decision Making
Box D
2 of 3 required
A
PROBLEM(S)
1
Minimal
2
Limited
3
Multiple
4
Extensive
B
DATA
1
Minimal
2
Limited
3
Moderate
4
Extensive
C
RISK
Minimal
Low
(3)
Moderate
High
Type of
Medical Decision Making
Straightforward
LOW
Moderate
High
99212 / 99201
& 99202
99213 / 99203
99214 / 99204
99215 / 99205
20
21
Time Based Services
When to bill a visit based on “Time”
 If counseling and/or coordination of care dominates (more than 50%) the face-to-face contact with the
patient and/or family then time is the key factor in determining the level of service.
 Report the code that reflects the total time of the patient visit (history, exam, medical decision making +
counseling)

Typical Time
New Patient
Typical Time
Established Patient
99201 – 10 minutes
99202 – 20 minutes
99203 – 30 minutes
99204 – 45 minutes
99205 – 60 minutes
99212 – 10 minutes
99213 – 15 minutes
99214 – 25 minutes
99215 – 40 minutes
Examples

25 minute visit, established patient
15 minutes Counseling
10 minutes History, Exam, Medical Decision Making
ASK YOURSELF:
 Is the service based on time or history, exam, medical decision making?
Answer: Time
 What is the total time of the visit?
Answer: 25 minutes
 What is the appropriate visit code to report based on the “typical time” of 40 minutes for an
established patient?
Answer: 99214
 25 minute visit, new patient
15 minutes Counseling
10 minutes History, Exam, Medical Decision Making (detailed history and
exam, moderate complexity medical decision making)
ASK YOURSELF:
 Is the service based on time or history, exam, medical decision making?
Answer: Time
 What is the total time of the visit?
Answer: 25 minutes
 What is the correct code based on History, Exam and Medical Decision Making?
Answer: 99203
22
Consultation vs. Referral
Consultation
Must be requested by the patient’s
attending physician
Attending physician must document the
need for a consultation in the medical
record
The patient presents with suspected
problem or condition
Consultant must render an opinion or advice
Consultant may initiate diagnostic and/or
therapeutic services
A formal response containing the opinion or
advice must be submitted to the attending
physician by the consultant
Office or Other Outpatient Consultations
CPT 99241 – 99245
Referral
Involves the transfer of care of the patient
from one physician to another
Patient presents with known problem or
condition
Initial patient visit CPT 99201 – 99205
Established patient visit CPT 99211 - 99215
No written response required
Initial Inpatient Consultation
CPT 99251 - 99255
Referring physician name required in Box
17 of the HCFA (referring physician field)
Remember the three “R’s” for a consultation: Request, Render & Response
23