Columbia University Medical Center - Billing Compliance Program
Blue Line
Top Menu Graphic
Research
Blue bar



Documentation Guidelines for CPT Evaluation and Management Services                         

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

Top