E&M Coding Quick Reference
Select the correct office/outpatient E&M code using Medical Decision Making (MDM) or total time on the date of the encounter. Based on AMA CPT guidelines.
How MDM Works
Medical Decision Making is determined by evaluating three elements. The overall MDM level is set by the 2 highest of the 3 elements.
Problem Complexity
Number and complexity of problems addressed during the encounter
Data Reviewed
Amount and complexity of data to be reviewed and analyzed
Risk Assessment
Risk of complications and/or morbidity or mortality of patient management
Meet 2 out of 3 elements to determine the MDM level
MDM by Level
Each level defines the qualifying criteria for problems, data, and risk. New patient codes are listed first, established patient codes second.
N/A
99211 Est.May not require the presence of a physician or other qualified health care professional. All three MDM elements are not applicable.
Straightforward
Problems Addressed
Minimal
1 self-limited or minor problem
Data Requirements
Minimal or none
Risk of Morbidity
Minimal risk of morbidity from additional diagnostic testing or treatment
Low
Problems Addressed
Low
- • 2 or more self-limited or minor problems
- • 1 stable chronic illness
- • 1 acute, uncomplicated illness or injury
- • 1 stable acute illness
- • 1 acute, uncomplicated illness or injury requiring hospital or observation level of care
Data Requirements
Limited
Must meet 1 of 2 categories
Category 1: Tests & Documents
Any combination of 2 from:
- ◦ Review of external prior note(s) from each unique source
- ◦ Review of the result(s) of each unique test
- ◦ Ordering of each unique test
Category 2: Independent Historian
Assessment requiring an independent historian(s)
Risk of Morbidity
Low risk of morbidity from additional diagnostic testing or treatment
Moderate
Problems Addressed
Moderate
- • 1 or more chronic illnesses with exacerbation, progression, or side effects of treatment
- • 2 or more stable chronic illnesses
- • 1 undiagnosed new problem with uncertain prognosis
- • 1 acute illness with systemic symptoms
- • 1 acute complicated injury
Data Requirements
Moderate
Must meet at least 1 of 3 categories
Category 1: Tests, Documents, or Historians
Any combination of 3 from:
- ◦ Review of prior external note(s) from each unique source
- ◦ Review of the result(s) of each unique test
- ◦ Ordering of each unique test
- ◦ Assessment requiring an independent historian(s)
Category 2: Independent Interpretation
Independent interpretation of a test performed by another physician/other qualified health care professional (not separately reported)
Category 3: Discussion of Management
Discussion of management or test interpretation with external physician/other qualified health care professional/appropriate source (not separately reportable)
Risk of Morbidity
Moderate risk
Examples:
- • 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
High
Problems Addressed
High
- • 1 or more chronic illnesses with severe exacerbation, progression, or side effects of treatment
- • 1 acute or chronic illness or injury that poses a threat to life or bodily function
Data Requirements
Extensive
Must meet at least 2 of 3 categories
Category 1: Tests, Documents, or Historians
Any combination of 3 from:
- ◦ Review of prior external note(s) from each unique source
- ◦ Review of the result(s) of each unique test
- ◦ Ordering of each unique test
- ◦ Assessment requiring an independent historian(s)
Category 2: Independent Interpretation
Independent interpretation of a test performed by another physician/other qualified health care professional (not separately reported)
Category 3: Discussion of Management
Discussion of management or test interpretation with external physician/other qualified health care professional/appropriate source (not separately reportable)
Risk of Morbidity
High risk
Examples:
- • Drug therapy requiring intensive monitoring for toxicity
- • Decision regarding elective major surgery with identified patient or procedure risk factors
- • Decision regarding emergency major surgery
- • Decision regarding hospitalization or escalation of hospital level of care
- • Decision not to resuscitate or to de-escalate care because of poor prognosis
- • Parenteral controlled substances
* Each unique test, order, or document contributes to the combination of 2 or combination of 3 in Category 1.
Time-Based Coding
E&M codes may alternatively be selected based on total time spent on the day of the encounter.
New Patient
| Code | MDM Level | Total Time |
|---|---|---|
| 99202 | Straightforward | 15 min |
| 99203 | Low | 30 min |
| 99204 | Moderate | 45 min |
| 99205 | High | 60 min |
* If 75 minutes or longer, use code for Prolonged Services
Established Patient
| Code | MDM Level | Total Time |
|---|---|---|
| 99211 | Minimal | N/A |
| 99212 | Straightforward | 10 min |
| 99213 | Low | 20 min |
| 99214 | Moderate | 30 min |
| 99215 | High | 40 min |
* If 55 minutes or longer, use code for Prolonged Services
Prolonged Services
Code 99417 — Prolonged office or other outpatient E&M service(s) beyond the total time of the primary procedure, each 15 minutes. May only be reported in conjunction with 99205 or 99215 if codes were selected based on time alone and not MDM. A service of less than 15 minutes should not be reported.
New Patient Level 5 (99205)
| Total Duration | Codes |
|---|---|
| < 75 minutes | Not reported |
| 75–89 minutes | 99205 + 99417 (1x) |
| 90–104 minutes | 99205 + 99417 (2x) |
| 105+ minutes | 99205 + 99417 (3x+) |
Established Patient Level 5 (99215)
| Total Duration | Codes |
|---|---|
| < 55 minutes | Not reported |
| 55–69 minutes | 99215 + 99417 (1x) |
| 70–84 minutes | 99215 + 99417 (2x) |
| 85+ minutes | 99215 + 99417 (3x+) |
JARALL Medical Management Consulting offers this document solely for guidance and offers no assurances or guarantees regarding payment. Always check with your third-party payer.
CPT is a registered trademark of the American Medical Association. Copyright 2019 American Medical Association. All rights reserved.
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