CPT Coding Guidelines for Office Visits
Documentation in the clinical record must support the level of service as coded and billed.
The Key Components – History, Examination, and Medical Decision Making – must be considered in determining the appropriate code (level of service)
History
|
type of patient new est. |
type of history |
HPI |
details of History ROS |
other history |
|
|
99211 |
M.D. presence not required, minimal problem, typically 5 minute service | ||||
|
99201 |
99212 |
problem focused | brief (1-3 elements) | ||
|
99202 |
99213 |
exp. prob. focused |
brief (1-3 elements) | prob. pertinent (1 system) | |
|
99203 |
99214 |
detailed | ext. (≥4 elements) | extended (2-9 systems) | pertinent (1 area) |
|
99204 |
comprehensive | ext. (≥4 elements) | complete (≥10 systems) | complete (≥ 2 areas) | |
|
99205 |
99215 |
comprehensive | ext. (≥4 elements) | complete (≥10 systems) | complete (≥ 2 areas) |
Examination
|
type of patient new est. |
type of exam |
details of Examination |
|
|
99211 |
exam may not be necessary | ||
|
99201 |
99212 |
problem focused | limited – affected area or organ system |
|
99202 |
99213 |
exp. prob. focused | limited – affected area / organ system + other related / symptomatic areas |
|
99203 |
99214 |
detailed | extended of affected area / organ system + related / symptomatic areas |
|
99204 |
comprehensive | general multi-system exam or complete exam of single organ system | |
|
99205 |
99215 |
comprehensive | general multi-system exam or complete exam of single organ system |
Medical Decision Making
|
type of patient new est. |
type of decision making |
details of Medical Decision Making |
|||
|
# of diagnoses / management options |
amount/complexity of data | risk of complications / morbidity / mortality | |||
|
99211 |
may not require medical decision making | ||||
|
99201 |
straightforward |
minimal |
minimal |
minimal |
|
|
99202 |
99212 |
straightforward |
minimal |
minimal |
minimal |
|
99203 |
99213 |
low complexity |
limited |
limited |
low |
|
99204 |
99214 |
moderate complex. |
multiple |
multiple |
moderate |
|
99205 |
99215 |
high complexity |
extensive |
extensive |
high |
Note: for new patients, all three key components must meet or exceed the above requirements for a given level of service; for established patients, two of the three key components must meet or exceed the requirements.
|
Details of History HPI elements (8): ROS systems (14): location symptoms (e.g. cough) quality eyes severity ears/nose/throat/mouth duration cardiovascular timing respiratory context gastrointestinal modifying factors genitourinary assoc. signs/symptoms musculoskeletal integumentary other history areas neurologic (req. for 99203/14 & up) psychiatric past history endocrine family history hematologic/lymphatic social history allergic/immunologic |
|
∙ four additional factors may be considered in determining the appropriate code (level of service) for a visit:
- nature of the presenting problem (minimal, self-limited / minor, low, moderate, or high severity)
- coordination of care with other health care professionals *
- counseling *
- time – see chart below for “typical” time spent face-to-face with patient/family for the various levels of service
|
5 min. |
10 min. |
15min. |
20 min. |
25 min. |
30 min. |
40 min. |
45 min. |
60 min. |
|
| new patient |
99201 |
99202 |
99203 |
99204 |
99205 |
||||
| est. patient |
99211 |
99212 |
99213 |
99214 |
99215 |
* when counseling or coordination of care comprises more than 50% of the visit or service rendered, time is the key factor in determining the appropriate code and the total time spent should be clearly documented.
for more detail, please consult the AMA’s annual Physician’s Current Procedural Terminology, available from the AMA and
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