What changed in 2021
On January 1, 2021, the AMA rewrote the guidelines for office and other outpatient evaluation and management (E/M) services. History and exam no longer determine the level; they only need to be medically appropriate. The level is now chosen by either medical decision making (MDM) or total time on the date of the encounter. Code 99201 was deleted, so the new-patient range starts at 99202.
This guide covers leveling by medical decision making, which is how most urgent care, primary care and pediatric visits are coded.
Levels and codes
| Level of MDM | New patient | Established patient |
|---|---|---|
| Straightforward | 99202 | 99212 |
| Low | 99203 | 99213 |
| Moderate | 99204 | 99214 |
| High | 99205 | 99215 |
A patient is new if they have not received professional services from the physician or another physician of the same specialty and subspecialty in the same group within the past three years. Base this on the patient's actual visit history, not on how the appointment was booked.
Element 1: Number and complexity of problems addressed
A problem is addressed when it is evaluated or treated at the encounter. Listing a diagnosis, or noting that another clinician manages it, does not make it addressed. Referring a problem without evaluating it, or without considering treatment, does not count either.
- Minimal: one self-limited or minor problem.
- Low: two or more self-limited or minor problems; one stable chronic illness; one acute, uncomplicated illness or injury; or one stable acute illness.
- Moderate: one or more chronic illnesses with exacerbation, progression or side effects of treatment; two or more stable chronic illnesses; one undiagnosed new problem with uncertain prognosis; one acute illness with systemic symptoms; or one acute complicated injury.
- High: one or more chronic illnesses with severe exacerbation, progression or side effects of treatment; or one acute or chronic illness or injury that poses a threat to life or bodily function.
Note the definition of systemic symptoms: for a minor illness, general symptoms like fever, body aches or fatigue don't by themselves make it an acute illness with systemic symptoms.
Element 2: Amount and complexity of data to be reviewed and analyzed
Data is counted in categories. A unique test is defined by its CPT® code, so a panel reported under one code is one test, and ordering a test includes reviewing its result.
- Limited: at least one of two categories. (1) Any two of: review of prior external notes from each unique source; review of the result of each unique test; ordering of each unique test. (2) Assessment requiring an independent historian.
- Moderate: at least one of three categories. (1) Any three of: external notes from each unique source, each unique test result reviewed, each unique test ordered, or an independent historian. (2) Independent interpretation of a test performed by another physician (not separately reported). (3) Discussion of management or test interpretation with an external physician or other qualified professional.
- Extensive: at least two of the three moderate categories.
Element 3: Risk of complications and/or morbidity or mortality of patient management
- Minimal: for example, rest, fluids or supportive care.
- Low: for example, over-the-counter drugs.
- Moderate: for example, prescription drug management; a decision about minor surgery with risk factors; a decision about elective major surgery without risk factors; or a diagnosis or treatment significantly limited by social determinants of health.
- High: for example, drug therapy requiring intensive monitoring for toxicity; a decision about elective major surgery with risk factors or emergency major surgery; a decision about hospitalization or escalation of care; or a decision not to resuscitate or to de-escalate care because of poor prognosis.
The 2-of-3 rule
The level of MDM is the highest level at which two of the three elements are met or exceeded. Put another way: rank the three element levels and take the middle one.
To try any combination of the three elements and see the level it adds up to, use the MDM level picker. To see the elements worked out on a real note, use the free E/M level calculator.
Common MDM mistakes that cause audits
- Counting problems that were only listed. The assessment may list five diagnoses; only those evaluated or treated today count.
- Counting a specialist's problem. A condition followed by another clinician, with no assessment at this visit, isn't addressed.
- Counting the BMI as a problem. A weight diagnosis listed only because of the BMI, with nothing in the plan, isn't addressed. If the plan counsels on it or orders related labs, it is.
- Counting screening and service codes as problems. Codes that describe the reason for the encounter, such as a screening, a vaccination or counseling, are not problems addressed.
- Counting results twice. A test ordered at this visit already counts when ordered. A result from a test you ordered at an earlier visit was counted at that visit.
- Unnamed independent historians. The note should show who gave the history, such as a parent or caregiver, and why.
- Leveling to the provider's selection. The billed level must be supported by the documentation. When the two disagree, in either direction, a coder should review it before the claim goes out.
This guide summarizes the AMA CPT® E/M guidelines for office and other outpatient services for educational purposes. Always refer to the current AMA CPT® code set and your payer's policies. CPT® is a registered trademark of the American Medical Association.