Documentation Guidelines for CPT E&M Codes

Introduction

The Current Procedural Terminology (CPT) manual, published annually by the American Medical Association (AMA) has definitive documentation guidelines that are required for each level of service code within the various E&M categories.

The E&M categories for office/outpatient; office and in-patient consultations; and emergency room services each have five levels of coding.

The E&M categories of initial and subsequent hospital visits each have three levels of coding.

The seven components to the code selection are:

  • The extent of History
  • The extent of Exam
  • The extent of Medical Decision Making
  • New or established patient
  • Nature of the presenting problem
  • Counseling or coordination of care
  • Amount of time spent with the patient

The charts that follow address the three KEY components to consider when selecting the level of code:

  • History
  • Exam
  • Medical Decision Making

New patients and consultations require that the three key components be met or exceeded.

Established patients and subsequent visits require that two of the three key components be met or exceeded.

Code Selection

The information provided at the top of the chart for each category will inform you if three or two key components must be met or exceeded to select the code.

  1. Select the appropriate level of history, exam, and medical decision making.
  2. If a row has two or three circles, select the code associated with that row.
  3. If several rows have one circle each, find the row that contains the second circle, and select the code associated with that row.

Determine the Level of HISTORY

Level

Type of History

CC

HPI

ROS

PFSH

1&2

Problem Focused

Yes

1-3 elements

N/A

N/A

3

Expanded Problem Focused

Yes

1-3 elements

1

N/A

4

Detailed

Yes

4 elements

2-9

1 element

5

Comprehensive

Yes

4 or more

10+

2 est. pt.
3 new pt.

CC=chief complaint; HPI=hx of present illness; ROS=review of systems; PFSH=past family social hx

Determine the Level of EXAMINATION

Level

Type of Examination

Body Systems Examined

1&2

Problem Focused

One

3

Expanded Problem Focused

Affected area and additional systems up to seven

4

Detailed

Seven

5

Comprehensive

Eight or more systems

Determine the COMPLEXITY of MEDICAL DECISION MAKING

Level

Decision

# of Dx's/Mgt Options

Amt/Complexity of Data

Risk of Complications

1&2

Straightforward

Minimal (1)

Minimal or none (1)

Minimal (1)

3

Low Complexity

Limited (2)

Limited (2)

Low (2)

4

Moderate Complexity

Multiple (3)

Moderate (3)

Moderate (3)

5

High Complexity

Extensive (4+)

Extensive (4+)

High (4)

Decision Making (2 of 3 required)

  • A. Number of diagnoses or management options: clinical impressions, referrals, changes in treatment.
  • B. Amount and/or complexity of data to be reviewed: test and procedures ordered, reviewed, and /or discussed as well as old records reviewed.
  • C. Risk of complexity/morbidity/mortality.

1. Dx and Management Options
Self-limiting/minor problem, stable, improved, worsening (pt.) max = 2
Established problem, stable, improved well controlled/resolving or resolved (1 pt.)
Established problem, worsening, failing to respond, inadequately controlled (2 pts.)
New Problem, no additional workup planned (3 pts.) max = 1
New problem with additional workup planned (4 pts.)

TOTAL = _______

2. Amount and /or Complexity of Data
Discuss tests with performing physician (1 pt.)
Ordered/reviewed labs/x-rays/tests from medicine section of CPT (1 pt.)
Decision to obtain old records/hx from someone other than the patient (1 pt.)
Independent review of tracings, specimens or x-rays (2 pts.)
Review/summarize old records /hx from someone other than the patient (2 pts.)

TOTAL = ________

Documentation Guidelines for CPT Evaluation and Management Services

Determine the Level of EXAMINATION

 

Level

Type of Examination

Body Systems Examined

1&2

Problem Focused

One

3

Expanded Problem Focused

Affected area and additional systems up to seven

4

Detailed

Seven

5

Comprehensive

Eight or more systems

Determine the COMPLEXITY of MEDICAL DECISION MAKING

Level

Decision

# of Dx's/Mgt Options

Amt/Complexity of Data

Risk of Complications

1&2

Straightforward

Minimal (1)

Minimal or none (1)

Minimal (1)

3

Low Complexity

Limited (2)

Limited (2)

Low (2)

4

Moderate Complexity

Multiple (3)

Moderate (3)

Moderate (3)

5

High Complexity

Extensive (4+)

Extensive (4+)

High (4)

Decision Making (2 of 3 required)

  • A. Number of diagnoses or management options: clinical impressions, referrals, changes in treatment.
  • B. Amount and/or complexity of data to be reviewed: test and procedures ordered, reviewed, and /or discussed as well as old records reviewed.
  • C. Risk of complexity/morbidity/mortality.

1. Dx and Management Options
Self-limiting/minor problem, stable, improved, worsening (pt.) max = 2
Established problem, stable, improved well controlled/resolving or resolved (1 pt.)
Established problem, worsening, failing to respond, inadequately controlled (2 pts.)
New Problem, no additional workup planned (3 pts.) max = 1
New problem with additional workup planned (4 pts.)

TOTAL = _______

2. Amount and /or Complexity of Data
Discuss tests with performing physician (1 pt.)
Ordered/reviewed labs/x-rays/tests from medicine section of CPT (1 pt.)
Decision to obtain old records/hx from someone other than the patient (1 pt.)
Independent review of tracings, specimens or x-rays (2 pts.)
Review/summarize old records /hx from someone other than the patient (2 pts.)

TOTAL = ________

Decision Making (2 of 3 required)

  • A. Number of diagnoses or management options: clinical impressions, referrals, changes in treatment.
  • B. Amount and/or complexity of data to be reviewed: test and procedures ordered, reviewed, and /or discussed as well as old records reviewed.
  • C. Risk of complexity/morbidity/mortality.

1. Dx and Management Options
Self-limiting/minor problem, stable, improved, worsening (pt.) max = 2
Established problem, stable, improved well controlled/resolving or resolved (1 pt.)
Established problem, worsening, failing to respond, inadequately controlled (2 pts.)
New Problem, no additional workup planned (3 pts.) max = 1
New problem with additional workup planned (4 pts.)

TOTAL = _______

2. Amount and /or Complexity of Data
Discuss tests with performing physician (1 pt.)
Ordered/reviewed labs/x-rays/tests from medicine section of CPT (1 pt.)
Decision to obtain old records/hx from someone other than the patient (1 pt.)
Independent review of tracings, specimens or x-rays (2 pts.)
Review/summarize old records /hx from someone other than the patient (2 pts.)

 

TOTAL = ________

Table of Risk

Total is equal to the highest level of risk in any one category.

This table is to be used as a guideline for risk. It is not considered to be comprehensive.

TOTAL = _________

(Total = highest risk in any one category)

Level of Risk

Presenting
Problem(s)

Diagnostic
Procedure(s) Ordered

Management
Options Selected

Minimal

One self-limited or minor problem, e.g., cold, insect bite, tinea corpis

Laboratory tests requiring venipuncture

Chest x-rays

EKG/EEG

Urinalysis

Ultrasound, e.g., echo-cardiography

KOH prep

Rest

Gargles

Elastic bandages

Superficial dressings

Low

Two or more self-limited or minor problems

One stable chronic illness, e.g., well controlled hypertension or non-insulin dependent diabetes, cataract, BPH

Acute uncomplicated illness or injury, e.g., cystitis, allergic rhinitis, simple sprain

Physiologic tests not under stress, e.g., pulmonary function tests

Non-cardiovascular imaging studies with contrast, e.g., barium enema

Superficial needle biopsies

Clinical laboratory tests requiring arterial puncture

Skin biopsies

Over-the-counter drugs

Minor surgery with no identified risk factors

Physical therapy

IV fluids without additives

Moderate

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, e.g., lump in breast

Acute illness with systemic symptoms, e.g., pyelonephritis, pneumonitis, colitis

Acute complicated injury, e.g., head injury with brief loss of consciousness

Physiologic tests under stress, e.g., cardiac stress test, fetal contraction stress test

Diagnostic endoscopies with no identified risk factors

Deep needle or incisional biopsy

Cardiovascular imaging studies with contrast and no identified risk factors, e.g., arteriogram, cardiac catheterization

Obtain fluid from body cavity, e.g., lumbar puncture, thora- centesis, culdocentesis

Minor surgery with identified risk factors

Elective major surgery (open, percutaneous or endoscopic) with no identified risk factors

Prescription drug management

Therapeutic nuclear medicine

IV fluids with additives

Closed treatment of fracture or dislocation without manipulation

High

One or more chronic illnesses with severe exacerbation, pro- gression, or side effects of treatment

Acute or chronic illnesses or injuries that pose a threat to life or bodily function, e.g., multiple trauma, acute MI, pulmonary embolus, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness with potential threat to self or others, peritonitis, acute renal failure

An abrupt change in neurologic status, e.g., seizure, TIA, weakness, or sensory loss

Cardiovascular imaging studies with contrast with identified risk factors

Cardiac electrophysiological tests

Diagnostic endoscopies with identified risk factors

Discography

Elective major surgery (open, percutaneous or endoscopic) with identified risk factors

Emergency major surgery (open, percutaneous or endoscopic)

Parenteral controlled substances

Drug therapy requiring intensive monitoring for toxicity

Decision not to resuscitate or to deescalate care because of poor prognosis


(Please note that Federal Payers, such as Medicare/Medicaid no longer recognize any category of consultation CPT Codes for reimbursement)

Outpatient/Office Coding

Consultations - office/outpatient (meet or exceed all 3 elements)
History Exam Decision Making Code
Problem focused:CC, HPI 1-3 Problem focused:1 body system Straight forward:Dx = Min;Data = Min/0; Risk = Min 99241
Expanded problem focused:CC, HPI 1-3, ROS 1 Expanded problem focused:affected area & others Straight forward:Dx = Min;Data = Min/0; Risk = Min 99242
Detailed:CC, HPI 4,ROS 2-9, PFSH 1 Detailed:7 systems Low:Dx = Ltd;Data = Ltd; Risk = Low 99243
Comprehensive:CC, HPI 4+,ROS 10, PFSH 3 Comprehensive:8 systems Moderate:Dx = Multi,Data = Mod, Risk = Mod 99244
Comprehensive:CC, HPI 4+,ROS 10+, PFSH 3 Comprehensive:8 systems High:Dx = Ext,Data = Ext, Risk = High 99245
Initial Office/Outpatient (meet or exceed all 3 elements)
History Exam Decision Making Code
Problem focused:CC, HPI 1-3 Problem focused:1 body system Straight forward:Dx=Min; Data=Min/0; Risk=Min 99201
Expanded Problem focused:CC, HPI 1-3, ROS 1 Expanded Problem focused:affected areas and others Straight forward:Dx = Min;Data = Min/0; Risk = Min 99202
Detailed:CC, HPI 4, ROS 2-9; PFSH 1 Detailed:7 systems Low:Dx = Ltd;Data = Ltd; Risk = Low 99203
Comprehensive:CC, HPI 4+,ROS 10+, PFSH 3 Comprehensive:8 or more systems Moderate:Dx = Multi,Data = Mod, Risk = Mod 99204
Comprehensive:CC, HPI 4+,ROS 10+, PFSH 3 Comprehensive:8 or more systems High:Dx = Ext,Data = Ext, Risk = High 99205
Subsequent Office/Outpatient (meet or exceed 2 of 3 elements)
History Exam Decision Making Code
Problem focused:n/a Problem focused:n/a Straight forward:n/a 99211
Problem focused:CC, HPI 1-3 Problem focused:1 system Straight forward:Dx = Min;Data = Min/0; Risk = Min 99212
Expanded problem focused:CC, HPI 1-3, ROS 1 Expanded problem focused:affected area & others Low:Dx = Ltd;Data = Ltd; Risk = Low 99213
Detailed:CC, HPI 4,ROS 2-9, PFSH 1 Detailed:7 systems Moderate:Dx = Multi,Data = Mod, Risk = Mod 99214
Comprehensive:CC, HPI 4+,ROS 10+, PFSH 2 Comprehensive:8 or more systems High:Dx = Ext,Data = Ext, Risk = High 99215

Inpatient Coding

Consultations - Initial Inpatient (meet or exceed all 3 elements)
History Exam Decision Making Code
Problem focused:
CC, HPI 1-3
Problem focused:1 body system Straight forward:Dx = Min;Data = Min/0; Risk = Min 99251
Expanded problem focused:
CC, HPI 1-3, ROS 1
Expanded problem focused:affected area & others Straight forward:Dx = Min;Data = Min/0; Risk = Min 99252
Detailed:
CC, HPI 4,ROS 2-9, PFSH 1
Detailed:7 systems Low:Dx = Ltd;Data = Ltd; Risk = Low 99253
Comprehensive:
CC, HPI 4+,ROS 10, PFSH 3
Comprehensive:8 systems Moderate:Dx = Multi,Data = Mod, Risk = Mod 99254
Comprehensive:
CC, HPI 4+,ROS 10+, PFSH 3
Comprehensive:8 systems High:Dx = Ext,Data = Ext, Risk = High 99255
Inpatient - Initial Visit (meet or exceed all 3 elements)
History Exam Decision Making Code
Detailed:CC, HPI 4,ROS 2-9, PFSH 1 Detailed:7 systems Straight forward or low:Dx = Min;Data = Min; Risk = Min 99221
Comprehensive:CC, HPI 4+,ROS 10, PFSH 3 Comprehensive:8 systems Moderate:Dx = Multi,Data = Mod, Risk = Mod 99222
Comprehensive:CC, HPI 4+,ROS 10+, PFSH 3 Comprehensive:8 systems High:Dx = Ext,Data = Ext, Risk = High 99223
Inpatient - Subsequent Visit (meet or exceeds 2 of 3 elements)
History Exam Decision Making Code
Problem focused:CC, HPI 1-3 Problem focused:1 body system Low or straight forward:Dx = Min/Ltd;Data = Min/Ltd; Risk = Min/Ltd 99231
Expanded problem focused:CC, HPI 1-3, ROS 1 Expanded problem focused:affected area & others Moderate:Dx = Multi;Data = Multi; Risk = Mod 99232
Detailed:CC, HPI 4,ROS 2-9, PFSH 1 Detailed:7 systems High:Dx = Ext;Data = Ext; Risk = High 99233