CPT Guidelines for Office Visits

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

Details of Examination

  body areas:                            organ systems:

  head, including face              constitutional

  neck                                             (vital signs, general)

chest, inc. breasts, axillae      eyes

  abdomen                                ears, nose, throat, mouth

  genitalia, groin, buttocks       cardiovascular

  back, including spine             respiratory

  each extremity                       gastrointestinal

                                                genitourinary

                                                musculoskeletal

                                                integumentary

                                                neurologic

                                                psychiatric

                                                hematologic/lymphatic

                                                        /immunologic            

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

∙ four additional factors may be considered in determining the appropriate code (level of service) for a visit:

  1. nature of the presenting problem (minimal, self-limited / minor, low, moderate, or high severity)
  2. coordination of care with other health care professionals *
  3. counseling *
  4. 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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