![]() ![]() Minimal risk of significant complications, morbidity and/or mortality.None or minimal amount and/or complexity of data to be reviewed. ![]() Minimal number of diagnoses or management options.Documentation needed (two of three below must be met or exceeded): Medical decision making that is straightforward.Limited examination of the affected body area or organ system.Patient presenting with minimal problems.The extent of such time must be documented in the medical record.Ĭurrent Procedural Terminology (CPT) codes and requirements When counseling and/or coordination of care dominates (more than 50 percent) the physician patient and/or family encounter (face-to-face time in the office or other outpatient setting), then time may be considered the key or controlling factor to qualify for a particular level of E/M services. When billing office or other outpatient services for established patients, two of the three key components must be fully documented in order to bill (other than 99211). The key components (elements of service) of evaluation & management (E/M) services are: Billing Instructions: Bill 1 unit per visit. Typically, 40 minutes are spent face-toface with the patient and/or family. Usually, the presenting problem(s) are of moderate to high severity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Billing Instructions: Bill 1 unit per visit.ĬPT 99215 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a comprehensive history a comprehensive examination medical decision making of high complexity. Typically, 25 minutes are spent face-to-face with the patient and/or family. Billing Instructions: Bill 1 unit per visit.ĬPT 99214 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a detailed history a detailed examination medical decision making of moderate complexity. Typically, 15 minutes are spent face-to-face with the patient and/or family. Usually, the presenting problem(s) are of low to moderate severity. Billing Instructions: Bill 1 unit per visit.ĬPT 99213 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: an expanded problem focused history an expanded problem focused examination medical decision making of low complexity. Typically, 10 minutes are spent face-to-face with the patient and/or family. Usually, the presenting Problem(s) are self limited or minor. Typically, 5 minutes are spent performing or supervising these services.īilling Instructions: Bill 1 unit per visit.ĬPT 99212 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a problem focused history a problem focused examination straightforward medical decision making. Usually, the presenting problem(s) are minimal. CPT 99211 Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional. ![]()
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