clinical logo and office visit coding

Date: Save Time On Research and Writing Hire a Pro to Write You a 100% Plagiarism-Free Paper. Get My Paper	Client Complexity: Comfort Assessment Episodic (Acute Condition) Multiple/Chronic/Controlled Disease Save Time On Research and Writing Hire a Pro to Write You a 100% Plagiarism-Free Paper. Get My Paper Multiple/Chronic/Uncontrolled Disease Single/Chronic/Controlled Disease Single/Chronic/Uncontrolled Disease Wellness Screening/HPDP Immunizations	Type of Visit: Acute/Episodic Care Other Chronic Illness Management Visit Postpartum Visit DOT Physical Pre- Employment Physical Family Planning Visit Prenatal Visit Health Maintenance Office Visit School Physical Immunizations STD/STI Visit IUD Placement/Check Well Child Exam Menopause Counseling Women’s Well Visit New OB Visit
CC:
Initials:	Diagnostics: Cardiopulmonary Laboratory Radiology Screening Tools Other
Age:
Gender: M / F	Procedures and Skills:
Ethnicity:	Medications:
Minutes:
Student Level of Function: 100 75 50 25	Education:
Type of Site:	Therapeutics:
Follow up:	Referrals:
Physical Exam: Cardiac Constitutional/VS Derm Development Endocrine GI Genitalia GU Gyne HEENT Lymph/Immuno Med Rec Musculoskeletal Neuro OB Other Pain Psych Respiratory
ICD- 10	CPT
Comments

Office Visit E&M Coding Cheat Sheet

 

 

Medical Decision Making Points 
Need 2 out of 3 

 

  99212  99213  99214 

Problems  1  2  3 

Data  1  2  3 

Risk  Minimal  Low  Moderate 

Problem points 

Self-limited or minor (max 2)  1 

Established problem, stable or improving  1 

Established problem, worsening  2 

New problem, no workup planned (max 2)  3 

New problem, additional workup planned  4 

 
Data Reviewed Points 

 

Review/order lab tests  1 

Review/order x-rays  1 

Review/order other tests (EKG, echo, etc)  1 

Discuss test results with performing physician  1 

Independent review of image, tracing  2 

Decision to obtain old records  1 

Review and summation of old records  2 

 

© Real World NP LLC 2020 

Documentation Required for Each Level 
Established patients 

 
  99212  99213  99214 

HPI (history)  1-3 elements (brief)  1-3 elements (brief)  >4 elements 
(extended) 

ROS (history)  –  1 system (pertinent)  2-9 systems 
(extended) 

PFSH (history)  –  –  At least 1 relevant 

Physical exam  1-5 elements/ one 
body area/organ 
system 

6 elements/ 2 organ 
systems or body 
areas 

12 elements / 5-7 
organ systems or 
body areas 

MDM  Straightforward  Low complexity  Moderate 
complexity 

Time  10 mins  15 mins  25 mins 

New patients 

  99203  99204  99205 

HPI (history)  4+ elements  4+ elements  4+ elements 

ROS (history)  2 systems  10 systems  10 systems 

PFSH (history)  1  1  3 

Physical exam  12 elements  18 elements  18 elements 

MDM  Low  Moderate  High 

Time  30  45  60 

References
https://www.aafp.org/fpm/2018/0700/p5.html
https://www.aafp.org/fpm/2003/0900/p33.html
https://www.aafp.org/fpm/2007/0100/p21.html
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/
Downloads/eval-mgmt-serv-guide-ICN006764

© Real World NP LLC 2020 

https://www.aafp.org/fpm/2018/0700/p5.html

https://www.aafp.org/fpm/2003/0900/p33.html

https://www.aafp.org/fpm/2007/0100/p21.html

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764