Table 1: NEW PATIENT (not seen by practice for 3 years) & CONSULTATION (no time limits).

Minimum Documentation Requirements

Key Components: History, Exam, Medical Decision Making
All 3 key components must be met (or exceeded) to qualify for a particular level code.
Code is determined by the lowest of the 3 components. (left-most column).
Time is a stand alone contributing component in specific circumstances described below.

History

Table 2: ESTABLISHED PATIENT (seen in practice with in 3 years) Minimum Documentation Requirements
Key Components: History, Exam, Medical Decision Making
Only 2 of the 3 key components must be met (or exceeded) to qualify for a particular code level.
The lower of the 2 components chosen determines code. (left-most column of 2 components chosen).
Time is a stand alone contributing component in specific circumstances described below.
(note: CPT code 99211 has no documentation requirements for the 3 key components.)

Focused

Expanded

Detailed

Comprehensive

Comprehensive

Chief Complaint
History of Present Illness
Location, Quality, Severity, Timing,
Duration, Context, Modifying
Factors, Associated Symptoms.
Review of Systems (14 systems)
Symptoms NOT Diseases
Past, Family, and Social History
3 areas: Past (illness, injury, meds,
surgery, allergy) / Family/ Social

1
1

1
1

1
4

1
4

1
4

10

10

Exam

Focused

Expanded

Bullets (see bullet counter)

Detailed

Comprehensive

Comprehensive

30

30

12

History

Focused

Expanded

1
1

1
1

1
4

1
4

10

Chief Complaint (CC on every note)

History of Present Illness
Location, Quality, Severity, Duration,
Timing, Context, Modifying Factors,
Associated Symptoms
Review of Systems (14 systems)
Symptoms NOT Diseases
Past, Family, and Social History
3 areas: Past (illness, injury, surgery,
meds, allergy) Family/ Social

Straight
Forward

(2 out of 3 Data,Diagnosis,Risk)
1
Data add points (# points)
(2) Interpret Imaging
(2) Review/Summary record and/or
curbSide and/or Translator
and/or History from other
(1) Order imaging or review report
(1) Order lab or review report
(1) order tests (EMG, Vasc. Lab,
PFTs etc.) or review report
(1) Review with performing MD
(1) Order old records
Diagnosis add points (# points)
1
(1) Minor Problem (max of 2)
(1) Established Problemstable or
better (each)
(2) Estab. Prob.worse (each)
(3) New prob. no work up planned
(max of 1)
(4) New prob. work up planned
(each)
Rest
Risk
Management options selected,
Ace Wrap
Lab Test
Diagnostic procedure ordered,
Minor (bug
bite, cold)
Presenting problem

Time (minimum in minutes) Must

document that face to face and >
50% counseling, and summarize
the counseling provided.

Code

Need 3/3 key components for

Dictation. Lowest component
determines code.(or Time)

Straight
Forward

Low

Moderate

High

Rest
Ace Wrap
Lab Test
Minor (bug
bite, cold)

OTC
PT
X-ray
Arterial punt.
Biopsy
(superficial)
1 problem

Prescription Med
Injection (script)
Aspiration
Surgery
Fracture/Dislocation
(no manipulation)
Biopsy (deep)
MRI, CT, BS
X-ray 2 area
exacerbation
2 chronic probs

Surgery with risk

Emergency Surgery
Fracture/Dislocation
(with manipulation)
Neuro Loss
Discography
Myelography
Arthrogram
Toxic Rx monitoring
Life or limb

N 10
C 15

N 25
C 30

N 30
C 40

N 45
C 60

N 60
C 80

N 99201
C 99241

N 99202
C 99242

N 99203
C 99243

N 99204
C 99244

N 99205
C 99245

Comprehensive

Exam

Focused

Expanded

Medical Decision Making

Straight
Forward

Low

Presenting problem

Rest
Ace Wrap
Lab Test
Minor
(bug bite,
cold)

OTC
PT
X-ray
Arterial punt.
Biopsy
(superficial)
1 problem

Prescription Med
Injection (script)
Aspiration
Surgery
Fracture/Dislocation
(no manipulation)
Biopsy (deep)
MRI, CT, bone scan
X-rays 2 area
exacerbation
2 chronic probs

Surgery w risk
Emergency Surgery
Fracture/Dislocation
(with manipulation)
Neuro Loss
Discography
Myelography
Arthrogram
Toxic drug monitoring
Life or limb

Time (minimum in minutes) Must

10

15

25

40

99212

99213

99214

99215

Number of Bullets (see bullet counter)

Medical Decision Making

Detailed

(2 out of 3 Data,Diagnosis,Risk)
Data add points (# points)
(2) Interpret Imaging
(2) Review/Summary record and/or
curbSide and/or Translator/ History
from other
(1) Order imaging or review report
(1) Order lab or review report
(1) order tests (EMG, Vasc. Lab,
PFTs etc.) or review report
(1) Review with performing MD
(1) Order old records
Diagnosis add points (# points)
(1) Minor Problem (max of 2)
(1) Established Problemstable or
better (each)
(2) Estab. Prob.worse (each)
(3) New prob. no work up planned
(max of 1)
(4) New prob. work up planned (each)
Risk
Management options selected,
Diagnostic procedure ordered,

Detailed

Comprehensive
12

30

Moderate

High

document that face to face and > 50%

counseling, and summarize the
counseling provided.

Code

Need 2/3 key components for Dictation.

Lower component (of top 2) determines
code. (or Time)

Table 3:

Bullet Counters

Chief Complaint Bullet counter

Every note needs chief complaint: new problems and follow ups

1
2
3
4
5
6
7
8

Element
Location
Quality
Severity
Duration
Timing
Context
Modifying Factors
Assoc. Symptoms

History of Present Illness Bullet counter

Description examples
site of problem, diffuse, localized, radiating
sharp, dull, throbbing, stabbing, burning
pain scale
intermittent, constant, length of time
exercise, nightly, after meals, etc.
improving, worsening, recurrent, etc.
what makes better, worse
bruising, numbness, tingling, locking, swelling, etc.

Note: One bullet per numbered element described.

1
2
3
4
5
6
7
8
9
10
11
12
13
14

System
Constitutional
Eyes
ENT
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Musculoskeletal
Skin
Neurologic
Psychiatric
Hematologic
Endocrine
Allergic

Review of Systems Bullet counter

Symptoms examples
unexpected weight loss, weight gain, fever, chills, fatigue
corrective lenses, blurred/double vision, eye pain, redness, watering
headache, difficulty swallowing, nose bleeds, ringing in ears, earaches
chest pain, palpitations, fainting, murmurs
short of breath, wheezing, cough, tightness, inspiration pain, snoring
heartburn, nausea, vomiting, constipation, diarrhea, bloody/tarry stools
frequency, urgency, difficult / painful urination, flank pain, bleeding
joint pains, swelling, instability, stiffness, redness, heat, muscle pain
skin changes, poor healing, rash, itching, redness
numbness/tingling, unsteady gait, dizziness, tremors, seizure
nervousness, anxiety, depression, hallucinations
easy bleeding, bruising
excessive thirst or urination, heat/cold intolerable
reaction to foods or environment

Note 1: One bullet for each system described.

Note 2: Symptoms (chest pain, shortness of breath) NOT Diseases (heart attack, COPD)
Note 3: This section may be obtained by ancillary staff or patient questionnaire. Physician to initial and date form and
refer to in the evaluation.
Note 4: For follow up visits a ROS obtained at a previous visit need not be re-recorded if the physician describes any
changes or notes that there has been no change in the previous information; and notes the date and location of the earlier
ROS.

1
2
3

History Area
Past History
Family History
Social History

Past, Family, and Social Histories Bullet Counter

Examples
Illnesses, hospitalizations, meds, injuries, surgeries, allergies
Inherited diseases, patient risk factors, medical events
Marital status, occupation, alcohol, tobacco, drug use

Note 1: One bullet for each of 3 history areas described.

Note 2: This section may be obtained by ancillary staff or patient questionnaire. Physician to initial and date form
and refer to in the evaluation.
Note 3: For follow up visits a PFSH obtained at a previous visit need not be re-recorded if the physician describes any
changes or notes that there has been no change in the previous information; and notes the date and location of the earlier
PFSH.

Musculoskeletal Exam Bullet Counter

Physical Exam Elements
Bullet count
Vital Signs (at least 3: BP, T, P, R, Ht. Wt.)
1
General Appearance
1
Orientation X 3
1
Mood and Affect
1
Gait and Station
1
BODY AREA (neck, back, RUE, LUE, RLE, LLE)
BA 1
BA 2
BA 3
Inspection/Palpation
1
1
1
Range of Motion
1
1
1
Stability
1
1
1
Strength
1
1
1
Skin
1
1
1
CV (any 1: pulse, temp, edema, swelling, varicosities)
1
Lymph (at least one area)
1
Sensation
1
DTR and Pathologic Reflexes
1
Coordination and Balance
1
Total
30

BA 4
1
1
1
1
1

Note 1: As a minimum, for a comprehensive exam all 4 bullets (Inspect/palpate, ROM, Stability, and Strength)
in 4 body areas and Skin in 4 body areas in addition to all other exam elements noted above must be documented.
Note 2: Documentation of multiple joints in the same body area is only 1 bullet for each descriptor (Inspect/palpate,
ROM, Stability, Strength). Example, ROM of right shoulder, R elbow and R wrist is one bullet. But, ROM R shoulder,
L shoulder, R knee, L knee, neck, and back is 6.

Table 4
Modifier Definition
24
Unrelated E/M in post op
25

57

E/M MODIFIERS

Clinical examples
Additional unrelated problem treated within
surgery global period.
Significant and Separately Identifiable E/M
x
Unplanned Injection on initial evaluation
x
Unplanned Injection on Follow up visit if
significant work is spent on E/M
x
E/M given for another joint not injected
x
Cant use for planned injection
E/M code on first visit, with fracture package
Decision for surgery made same day or day
before a major procedure. A major procedure is (if manipulation) or surgery global.
defined as a surgery / procedure with 90 global A visit the day of or day before surgery is part
of the global, unless decision for surgery is
days.
made at that visit.

References: 1. AAOS CPT Guide, 2007

2. AMA Principles of CPT coding, 2005
3. CMS 1997 Guidelines.
4. CPT 2007.
5. Karen Zupko and Associates.
6. Ritchie, Jack, Arthroscopy, Feb. 2002, supplement 1, pp 99-110.
AAOS Now, James Davidson MD, 2007
For additional information and instruction see: http://www.aaos.org/news/bulletin/may07/managing7.asp