E&M Coding
Elements of Medical Decision Making
Documentation Must Support 2/3 Elements
| Element 1 Number and Complexity of Problems Addressed | Element 2 Amount and/or Complexity Data to be Reviewed and Analyzed | Element 3 Risk of Complication and/or Morbidity or Mortality of Patient Management. | Level of MDM |
|---|---|---|---|
| 1 or more chronic illnesses with severe exacerbation, progression, or side effects of treatment; or 1 acute or chronic illness or injury that poses a threat to life or bodily function | Extensive (Must meet the requirements of at least 2 out of 3 categories) Category 1: Tests, documents, or independent historian(s) or Any combination of 3 from the following: (1) Review of prior external note(s) from each unique source; (2) Review of the result(s) of each unique test; (3) Ordering of each unique test; (4) Assessment requiring an independent historian(s)or Category 2: Independent interpretation of tests- Independent interpretation of a test performed by another physician or other qualified health care professional (not separately reported) or Category 3: Discussion of management or test interpretation: Discussion of management or test interpretation with external physician/other qualified health care professional/appropriate source (not separately reported) | High risk of morbidity from additional diagnostic testing or treatment Examples only: -Drug therapy requiring intensive monitoring for toxicity -Decision regarding elective major surgery with identified patient procedure risk factors -Decision regarding emergency major surgery -Decision regarding hospitalization -Decision not to resuscitate or to deescalate care because of poor prognosis | HIGH 99205 New Patient 99215 Established Patient |
| 1 or more chronic illnesses with exacerbation, progression, or side effects of treatment; or 2 or more stable chronic illnesses; or 1 undiagnosed new problem with uncertain prognosis; or 1 acute illness with systemic symptoms or 1 acute complicated injury | Moderate (Must meet the requirements of at least 1 out of 3 categories) Category 1: Tests, documents, or independent historian(s) or Any combination of 3 from the following: (1) Review of prior external note(s) from each unique source; (2) Review of the result(s) of each unique test; (3) Ordering of each unique test; (4) Assessment requiring an independent historian(s) or Category 2: Independent interpretation of tests Independent interpretation of a test performed by another physician/other/qualified health care professional (not separately reported); or Category 3: Discussion of management or test interpretation Discussion of management or test interpretation with external physician/other qualified health care professional\appropriate source (not separately reported) | Moderate Risk of morbidity from additional diagnostic testing or treatment Examples only: -Prescription drug management -Decision regarding minor surgery with identified patient or procedure risk factors -Decision regarding elective major surgery without identified patient or procedure risk factors -Diagnosis or treatment significantly limited by social determinants of health | MODERATE 99204 New Patient 99214 Established Patient |
| 2 or more self-limiting minor problem or 1 stable chronic illness (well-controlled HTN) or Acute uncomplicated illness or injury (cystitis, allergic rhinitis) | Limited (Must meet the requirements of at least 1 of the 2 categories) Category 1: Tests, documents, or independent historian(s) or Any combination of 2 from the following: (1) Review of prior external note(s) from each unique source; (2) Review of the result(s) of each unique test; (3) Ordering of each unique test; or Category 2: Assessment requiring an independent historian(s) (For the categories of independent interpretation of tests and discussion of management or test interpretation, see moderate or high) | Low risk of morbidity from additional diagnostic testing or treatment | LOW 99203 New Patient 99213 Established Patient |
| 1 self-limiting or minor problem (cold, tinea corporis) | Minimal or None. | Minimal risk of morbidity from additional diagnostic testing or treatment | STRAIGHT- FORWARD 99202 New Patient 99212 Established Patient |
Coding by Time
| New Patient Code | Total Time (minutes) |
|---|---|
| 99202 | 15-29 |
| 99203 | 30-44 |
| 99204 | 45-59 |
| 99205 | 60-74 |
| Established Pt Code | Total Time (minutes) |
|---|---|
| 99212 | 10-19 |
| 99213 | 20-29 |
| 99214 | 30-39 |
| 99215 | 40-54 |