An important guideline to remember when reporting office visits other than counseling and coordination of care is that only two of the three key components must be reported.
The following is a summary of the requirements for codes 99211 – 99215.
99211: 5 minutes and may not require the presence of a physician
99212: 10 minutes
A problem focused history
A problem focused examination
Straight forward decision making
99213: 15 minutes
An expanded problem focused history
An expanded problem focused examination
Medical decision making of low complexity
99214: 25 minutes
A detailed history
A detailed examination
Medical decision making of moderate complexity
99215: 40 minutes
A comprehensive history
A comprehensive examination
Medical decision making of high complexity
History and physical examination skills and documentation guidelines we were taught in medical training tend to produce a very high quality of medical care. But these do not always meet the guidelines in the multiple medical record components that are required by CPT coding system for E/M coding. To be more efficient and improve reimbursements, physicians must have a better understanding of the Current Procedural Terminology requirements. Future discussions in this section of the AHS website will include a comprehensive discussion of the three key components of CPT coding: History, Examination, and Medical Decision Making, as well as a review of the importance of understanding the Nature of the Presenting Problem in ensuring proper coding. The fourth quarterly future topic in this series will be devoted to the International Classification of Diseases (ICD – 9-CM) coding.
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