Medical Billing ToolsTM
Office/Outpatient Version
Provided by: Clyde P. Sanchez, CFNP, PhD

Decision Making

Documentation required for the complexity of medical decision making is divided into three areas according to the guidelines. These three areas are:
Only 2 of these 3 areas must be met.

These criteria will separate all patients into one of the following four areas:
The following table summarizes the criteria needed for each of these four areas:

# Of DX or Management Options
Amount and/or Complexity of Data
Risk of Complications
Type of Desicion
E & M Billing Code
Minimal or None Minimal
One self-limited minor problem
Straightforward New:
99201 & 99202
Established: 99212
2 to 3
Limited Limited
1. Two self-limited minor problems
2. One stable chronic illness or
3. One acute uncomplicated illness or injury
Low complexity New: 99203 or Established: 99213
4 to 7
Moderate Multiple
1. Chronic Illness with mild exacerbation
2. Two stable chronic illnessess
3. Undiagnosed new problem with uncertain prognosis
4. Acute illness with systemic sx's or acute complicated injury
Moderate complexity New: 99204 or Established: 99212
8 or more
Extensive High
1. Chronic Illness with severe exacerbation
2. Acute or chronic illnessess that pose a threat to life or bodily function
3. An abrupt change in neurologic status
High complexity New: 99205 or Established: 99215

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