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Home > Practice & Professional Development Library > Summarizing E/M CPT Codes

Summarizing E/M CPT Codes

By W. Bruce Milliman, ND, and Eva Miller, ND
(AMA - CPT/Editorial Panel/HCPAC, representing the AANP)

In the last five articles we have covered in detail the components of Evaluation and Management (E/M) CPT Codes. We are now ready to summarize it and put it all together.

Note: For clarity on medical decision making see table 1
Note: “When counseling and/or coordination of care dominates (more than 50%) of the physician/patient and/or family encounter, then time shall be considered the key or controlling factor to qualify for a particular level of E/M services. The extent of counseling and/or coordination of care must be documented in the medical record.” (CPT 2011)

New Patients (as written in CPT 2011)
99201 – Requires 3 key components
  • A problem focused history  (Chief complaint; brief history of present problem)
  • A problem focused examination (limited examination of the affected body area or organ system)
  • Straightforward medical decision making
    Presenting problems are self limited or minor
    Physician typically spends 10 minutes face to face with patient and/or family
99202 – Requires 3 key components
  • An expanded problem focused history (Chief complaints; brief history of present illness; problem pertinent system review)
  • An expanded problem focused examination (a limited exam of the affected body area and other symptomatic systems)
  • Straightforward medical decision making
    Presenting problems are of low to moderate severity
    Physician typically spends 20 minutes face to face with patient and/or family
99203 - Requires 3 key components
  • A detailed history (chief complaint; extended history of present illness, problem pertinent system review, pertinent past, family, and or social history directly related to the patients problems)
  • A detailed examination (An extended examination of the affected body area(s) and other symptomatic or related organ system(s).
  • Medical decision making of low complexity
    Presenting problems are of moderate severity

    Physician typically spends 30 minutes face to face with patient and/or family
99204 - Requires 3 key components
  • A comprehensive history (Chief complaint; extended history of present illness; review of systems related to problems identified in the history of present illness plus a review of all additional body systems; complete past family and social history).
  • A comprehensive examination (A general multisystem examination or a complete examination of a single organ system).
  • Medical decision making of moderate complexity
    Presenting problems are of moderate to high severity
    Physician typically spends 45 minutes face to face with patient and/or family
99205 - Requires 3 key components
  • A comprehensive history
  • A comprehensive examination
  • Medical decision making of high complexity
    Presenting problems are of moderate to high severity
    Physician typically spends 60 minutes face to face with patient and/or family
Established Patients (as written in CPT 2011)
99211 – for the evaluation and management of a patient that may not require the presence of a physician. Typically 5 minutes are spent performing or supervising these services.
99212 – Requires 2 of these 3 components
  • A problem focused history
  • A problem focused examination
  • Straightforward medical decision making
    Presenting problems are self limited or minor.
    Physician typically spends 10 minutes face to face with patient and/or family
99213 - Requires 2 of these 3 components
  • An expanded problem focused history
  • An expanded problem focused examination
  • Medical decision making of low complexity
    Presenting problems are of low to moderate severity
    Physicians typically spend 15 minutes face to face with patient and/or family
99214 - Requires 2 of these 3 components
  • A detailed history
  • A detailed examination
  • Medical decision making of moderate complexity
    Presenting problems are of moderate to high severity
    Physicians typically spend 25 minutes face to face with patient and/or family
99215 - Requires 2 of these 3 components
  • A comprehensive history
  • A comprehensive examination
  • Medical decision making of high complexity
    Presenting problems are of moderate to high severity
    Physicians typically spend 40 minutes face to face with patient and/or family

Table 1 (As written in CPT 2011)

To qualify for a given type of decision making two of the three elements in this table must be met or exceeded

Complexity of medical decision making

# of diagnoses or                    Amount and/or                        Risk of Complications              Type of

Management                            Complexity of Data                  and/or Morbidity                      Decision Making

Options                                    to be Reviewed                       Mortality

Minimal                                  Minimal/None                       Minimal                                 Straightforward

Limited                                   Limited                                   Low                                        Low complexity

Multiple                                  Moderate                                Moderate                               Moderate complexity

Extensive                               Extensive                               High                                        High complexity


KEY TO TABLE 1
Minimal: A problem that may not require the presence of a physician, but service is provided uner the supervision of a physician
Limited: A problem that runs a definite and prescribed course, is transient in nature, and is not likely to prematurely alter health status OR has good prognosis with management/compliance.
Low: A problem where the risk for morbidity without treatment is low, there is little to no risk of mortality without treatment; full recovery without functional impairment is expected.
Moderate: A problem where the risk of morbidity without treatment is moderate; there is moderate risk of mortality without treatment; uncertain prognosis OR increased probability of prolonged functional impairment.
High: A problem where the risk of morbidity without treatment is high to extreme; there is moderate to high risk of mortality without treatment OR high probability of severe, prolonged functional impairment.
 
This concludes our discussion on E/M services.
 
Future articles regarding specific questions about, or aspects of CPT will be willingly and happily written upon request by members to either Dr. Milliman or Dr. Miller.