All 3 components

History
Exam
MDM
Avg Time

NEW PATIENT OFFICE OR OTHER VISIT

99201
99202
99203
99204
PF
EPF
DET
COMP
PF
EPF
DET
COMP
SF
SF
LC
MC
10
20
30
45

University of Utah Health Sciences Center

INPATIENT SERVICES

OUTPATIENT SERVICES
99205
COMP
COMP
HC
60

ESTABLISHED OFFICE OR OTHER OUTPATIENT VISIT

99211
99212
99213
99214
99215
History
PF
EPF
DET
COMP
May not
Exam
PF
EPF
DET
COMP
require MD
MDM
SF
LC
MC
HC
Avg Time
5
10
15
25
40

INITIAL INPATIENT CONSULTATION

(NON-MEDICARE PATIENTS ONLY)
All 3 Components
99251
99252
99253
99254
History
PF
EPF
DET
COMP
Exam
PF
EPF
DET
COMP
MDM
SF
SF
LC
MC
Avg Time
20
40
55
80

REFERENCE GUIDE FOR EVALUATION AND MANAGEMENT SERVICES

99255
COMP
COMP
HC
110

2/3 components

NEW OR ESTABLISHED OUTPATIENT CONSULTATION

(NON-MEDICARE PATIENTS ONLY)
All 3 components
99241
99242
99243
99244
99245
History
PF
EPF
DET
COMP
COMP
Exam
PF
EPF
DET
COMP
COMP
MDM
SF
SF
LC
MC
HC
Avg Time
15
30
40
60
80
PROLONGED SERVICES
Outpatient Face to Face: (With patient or with medical decision maker)
+99354 Prolonged physician service in the outpatient setting, 30-74 min
+99355 Each additional 30 minutes of care
Face to Face start and stop time must be documented in the record
Outpatient or Inpatient Non Face to Face: (Without face-to face contact)
Prolonged physician service before/after direct (face-to-face)
+99358
patient care, 30-74 min
+99359 Each additional 30 minutes of care
Time must be documented in the record

OBSERVATION SERVICES
INITIAL OBS (ADMIT & DISCH. ON DIFFERENT DATE OF SERVICE)
All 3 components
99218
99219
99220
History
DET
COMP
COMP
Exam
DET
COMP
COMP
MDM
SF
MC
HC
Avg Time
NA
NA
NA

99217

OBSERVATION CARE DISCHARGE SERVICES

Observation care discharge day management for a patient
designated observation status.

INITIAL OBS (ADMIT & DISCHARGE ON SAME DATE OF SERVICE)

(Greater than 8 hours)
All 3 components
99234
99235
99236
History
DET
COMP
COMP
Exam
DET
COMP
COMP
MDM
SF
MC
HC
Avg Time
NA
NA
NA

INITIAL HOSPTIAL CARE & DAILY CARE

History
Exam
MDM
Avg Time

99238
99239

99291
+99292

ADMISSION
(3/3 components)
99221
99222
99223
DET
COMP
COMP
DET
COMP
COMP
SF/LOW
MC
HC
30
50
70

SUBSEQUENT
(2/3 components)
99231
99232
99233
PF
EPF
DET
PF
EPF
DET
SF/LOW
MC
HC
15
25
35

DISCHARGE SERVICES
Hospital discharge day management; 30 minutes or less
Hospital discharge day management; more than 30 minutes
Time must be documented in the record
CRITICAL CARE
Critical Care, E/M of critically ill/injured patient, first 30-74 min.
Each additional 30 minutes of care (list separately in addition to
code for primary service)
Time must be documented in the record

CHIEF COMPLAINT:
A concise statement describing the symptom, problem, condition,
diagnosis, physicians recommended return, or other factor that is the
reason for the encounter.
HISTORY OF PRESENT ILLNESS (HPI):
Elements: Location, Severity, Context, Quality, Duration, Timing,
Modifying Factors, Associated Signs & Symptoms
REVIEW OF SYSTEMS (ROS):
Constitutional Symptoms
Musculoskeletal
Eyes
Cardiovascular
Integumentary & Breast
Neurologic
Ears, nose, mouth, & throat
Psychiatric
Endocrine
Hematologic/Lymphatic
Respiratory
Allergenic/Immunologic
Gastrointestinal
Genitourinary

Past:
Family:
Social:

PROLONGED SERVICES
Inpatient Floor/Unit time
+99356 Prolonged physician service in the inpatient setting, 30-74 min
+99357 Each additional 30 minutes of care
Face to Face start and stop time must be documented in the record
Outpatient or Inpatient Non Face to Face: (Without face-to face contact)
Prolonged physician service before/after direct (face-to-face)
+99358
patient care, 30-74 minutes
+99359 Each additional 30 minutes of care
Time must be documented in the record
CPT codes are American Medical Association 2012
Created/Maintained by University Medical Billing& University Health Care
Compliance

PAST/FAMILY/SOCIAL HISTORY (PFSH):

Medications, illnesses, injuries, operations,
hospitalizations, allergies, dietary status.
Health status, diseases, or cause of death of family
members
Marital status, job, drug, etoh/tobacco use, sexual habits,
and education
HISTORY CODE GRID

Level
Problem
Focused PF
Expanded
Problem
Focused EPF
Detailed DET

Comprehensive
COMP

1.
2.
1.
2.
3.
1.
2.
3.
4.
1.
2.
3.
4.

Chief Complaint
Brief HPI (1-3 elements)
Chief Complaint
Brief HPI (1-3 elements)
Problem pertinent ROS (1 system)
Chief Complaint
Extended HPI (4+ elements)
Extended ROS (2-9 systems)
Pertinent PFSH (1 category)
Chief Complaint
Extended HPI (4+ elements)
Complete ROS (10+ systems)
Complete PFSH (3 categories)**

Revised 07/09/2012
**ED visits/ Established patient visit/ Domiciliary/Home Care only
require 2/3 PFSH to be complete.

TABLE OF RISK (Use highest level item) (3)

ELEMENTS OF MEDICAL DECISION MAKING

Constitutional (e.g., vital signs, general appearance)

Eyes
Ears, nose, mouth and throat
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Musculoskeletal
Skin
Neurologic
Psychiatric
Hematologic/lymphatic/immunologic

The extent of examinations performed and documented is dependent

upon clinical judgment and the nature of the presenting problem(s).
They range from limited examinations of single body areas to general
multi-system or complete single organ system examinations.

Level
Problem
Focused PF
Expanded
Problem
Focused - EPF
Detailed DET

Comprehensive
COMP

EXAMINATION CODE GRID

Perform and Document
A limited examination of the affected body area
or organ system. (1 system or body area)
A limited examination of the affected body area
or organ system and other symptomatic or
related organ system(s)
(2-4 systems or body areas)
An extended examination of the affected body
area(s) and other symptomatic or related organ
system(s).
(5-7 systems or body areas)
A general multi-system examination or
complete examination of a single organ
system. (8+ systems )

New problem(to examiner)

additional workup planned
Total:

X4

Minimal
Low

Amount and/or Complexity Data to be Reviewed (2)

Description
Points
Review and/or order clinical lab tests
1
Review and/or order radiology tests

Review and/or order tests in the medicine services

(ECG, Echography, etc)
Decision to obtain old records and/or obtain history from
someone other than the patient.
Review and summarize old records and/or obtain
history from someone other than the patient and/or
discussion of case with another healthcare provider.
Independent visualization of image, tracing, or
specimen itself (not review of report only).
Total:

1
1
2
2

Minimal
(1)

Limited
(2)

Multiple
(3)

Data
(2)

Minimal
or none
(0-1)

Limited
(2)

Multiple
(3)

Extensive
(4)

Risk
(3)

Minimal

Low

Moderate

High

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNEdWebGuide/Downloads/95Docguidelines.pdf
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNEdWebGuide/Downloads/97Docguidelines.pdf

Lab tests (other

than arterial)
Chest x-rays,
EKG, Ultrasound

2(+) self-limited or
minor problems

Physiologic tests
not under stress

1 stable chronic
illness

Non-cardio image
studies w/o contrast

Acute
uncomplicated
illness or injury

Superficial needle
biopsies

2(+) stable
chronic illnesses

Lab tests (arterial

puncture)
Physiologic tests
w/stress
Endoscopies w/o
risk factors
Deep biopsy

Management
Options Selected

Rest,
Gargles,
bandages,
superficial
dressings
OTC
Minor
surgery-no risk
factors.
PT/OT
IV fluids w/o
additives
Minor surgery
w/risk factors
Elective major
surgery w/o risk
factors
Prescriptions

Undiagnosed
problems with
unsure prognosis

Cardio imaging
w/contrast & no risk
factors

Acute illness w/
systemic sym.

Obtain fluid from

body cavity.

IV w/
additives

Cardio imaging
w/contrast & risk
factors

Closed fx or
dislocation w/o
manipulation
Elective major
surgery w/risk
factors

1(+) chronic
illnesses w/severe
exacerbation,
progression

Extensive
(4)

Using the adjacent point counting system is only a suggestion. Please see
the 1995 and 1997 Medicare regulations for complete details at:

One self-limited or
minor problem

Diagnostic
Procedure(s) Ordered

Acute
complicated injury

Determination of Medical Decision Making Level

Level Selection Must Meet or Exceed 2 of the 3 components
Straight
Low
Moderate
High
Forward
(LC)
(MC)
(HC)
(SF)
Options
(1)

Presenting Problem(s)

1(+) chronic
illness w/ mild
exacerbation,
progression

Moderate

For purposes of examination, the following organ systems are

recognized:

Number of Diagnoses or Management Options (1)

Description
Value
Points Total
Self-limited or minor (stable,
X1
improved, or worsening) (Max=2)
Established problem (to
X1
examiner); stable, improved
Established problem (to
X2
examiner); worsening or failing to
respond
New problem (to examiner); no
X3
additional workup planned

Level

High

1995 Evaluation & Management Guidelines

PHYSICAL EXAMINATION

Acute or chronic
illness/injuries that
pose a threat to
life/bodily function
Abrupt change in
neurologic status

Cardiac EP tests
Endoscopies
w/risk factors
Discography

Therapeutic
nuclear med.

Emergency
major surgery
Parenteral
controlled sub.
Drug therapy
w/ intensive
monitoring for
toxicity
DNR