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.
- Number of diagnoses or management options
- Amount and/or complexity of data to be reviewed
- Risk of complications and/or morbidity or mortality
These criteria will separate all patients into one of the following four areas:
- Straightforward decision
- Low complexity
- Moderate complexity
- High complexity
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 CodeMinimal
1Minimal or None Minimal
One self-limited minor problemStraightforward New:
99201 & 99202
or
Established: 99212Limited
2 to 3Limited Limited
1. Two self-limited minor problems
2. One stable chronic illness or
3. One acute uncomplicated illness or injuryLow complexity New: 99203 or Established: 99213 Multiple
4 to 7Moderate 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 injuryModerate complexity New: 99204 or Established: 99212 Extensive
8 or moreExtensive 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 statusHigh complexity New: 99205 or Established: 99215
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