assignment 2

Office Visit E&M Coding Cheat Sheet   

Medical Decision Making Points  Need 2 out of 3 

 

  99212  99213  99214 

Problems  1  2  3 

Data  1  2  3 

Risk  Minimal  Low  Moderate 

Problem points 

Self-limited or minor (max 2)  1 

Established problem, stable or improving  1 

Established problem, worsening  2 

New problem, no workup planned (max 2)  3 

New problem, additional workup planned  4 

  Data Reviewed Points 

 

Review/order lab tests  1 

Review/order x-rays  1 

Review/order other tests (EKG, echo, etc)  1 

Discuss test results with performing physician  1 

Independent review of image, tracing  2 

Decision to obtain old records  1 

Review and summation of old records  2 

 

© Real World NP LLC 2020 

Documentation Required for Each Level  Established patients 

 

  99212  99213  99214 

HPI (history)  1-3 elements (brief)  1-3 elements (brief)  >4 elements  (extended) 

ROS (history)  -  1 system (pertinent)  2-9 systems  (extended) 

PFSH (history)  -  -  At least 1 relevant 

Physical exam  1-5 elements/ one  body area/organ  system 

6 elements/ 2 organ  systems or body  areas 

12 elements / 5-7  organ systems or  body areas 

MDM  Straightforward  Low complexity  Moderate  complexity 

Time  10 mins  15 mins  25 mins 

New patients 

  99203  99204  99205 

HPI (history)  4+ elements  4+ elements  4+ elements 

ROS (history)  2 systems  10 systems  10 systems 

PFSH (history)  1  1  3 

Physical exam  12 elements  18 elements  18 elements 

MDM  Low  Moderate  High 

Time  30  45  60 

References https://www.aafp.org/fpm/2018/0700/p5.html https://www.aafp.org/fpm/2003/0900/p33.html https://www.aafp.org/fpm/2007/0100/p21.html https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/ Downloads/eval-mgmt-serv-guide-ICN006764.pdf

© Real World NP LLC 2020