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Last Modified: 7/3/2014 Location: FL, PR, USVI Business: Part B

Evaluation & management tips: Office or other outpatient services, established patient

Key points to remember

The key components (elements of service) of evaluation & management (E/M) services are:
1. History,
2. Examination, and
3. Medical decision-making.
When billing office or other outpatient services for established patients, 2 of the 3 key components must be fully documented in order to bill (other than 99211). When counseling and/or coordination of care dominates (more than 50%) the physician/patient and/or family encounter (face-to-face time in the office or other outpatient setting), then time may be considered the key or controlling factor to qualify for a particular level of E/M services. The extent of such time must be documented in the medical record.

CPT codes and requirements

99211 - 5 minutes (average)
Patient presenting with minimal problems
3 components not required
99212 - 10 minutes (average)
Problem focused history. Documentation needed:
Chief complaint
Brief history of present illness
Problem focused examination. Documentation needed:
Limited examination of the affected body area or organ system
Medical decision making that is straightforward. Documentation needed (2 of 3 below must be met or exceeded):
Minimal number of diagnoses or management options
None or minimal amount and/or complexity of data to be reviewed
Minimal risk of significant complications, morbidity and/or mortality
99213 - 15 minutes (average)
Expanded problem focused history. Documentation needed:
Chief complaint
Brief history of present illness
Problem pertinent review of systems
Expanded problem focused examination. Documentation needed:
Limited examination of the affected body area or organ system and any other symptomatic or related body area(s) or organ system(s)
Medical decision making that is of low complexity. Documentation needed (2 of 3 below must be met or exceeded):
Limited number of diagnoses or management options
Limited amount and/or complexity of data to be reviewed
Low risk of significant complications, morbidity and/or mortality
99214 - 25 minutes (average)
Detailed history. Documentation needed:
Chief complaint
Extended history of present illness
Extended review of systems
Pertinent past, family and/or social history
Detailed examination. Documentation needed:
Extended examination of the affected body area(s) or organ system(s) and any other symptomatic or related body area(s) or organ system(s)
Medical decision making that is of moderate complexity. Documentation needed (2 of 3 below must be met or exceeded):
Multiple number of diagnoses or management options
Moderate amount and/or complexity of data to be reviewed
Moderate risk of significant complications, morbidity and/or mortality
99215 - 40 minutes (average)
Comprehensive history. Documentation needed:
Chief complaint
Extended history of present illness
Complete review of systems
Complete past, family, and social history
Comprehensive examination. Documentation needed:
A general multi-system examination OR complete examination of single organ system and other symptomatic or related body area(s) or 8 or more organ system(s)
Medical decision making that is of high complexity. Documentation needed (2 of 3 below must be met or exceeded):
Extensive number of diagnoses or management options
Extensive amount and/or complexity of data to be reviewed
High risk of significant complications, morbidity and/or mortality

First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.