Understanding E/M Coding Levels

Use the following table as a guide to help you select the correct level of medical decision making (MDM) for in-office visits. The table explains which elements (and how many) contribute to MDM levels and their associated CPT codes. To qualify for a particular MDM level, two of the three elements for that level must be met or exceeded. This table is a reproduction of Table 2 in AMA’s E/M Code and Guideline Changes .

Code Level of MDM
(Based on 2 out of 3 Elements of MDM) 1		 Elements of Medical Decision Making
Number and Complexity of Problems Addressed Amount and/or Complexity of Unique Data to be Reviewed and Analyzed Risk of Complications and/or Morbidity or Mortality of Patient Management

99211

N/A

N/A

N/A

N/A

99202

99212

Straightforward

Minimal

  • 1 self-limited or minor problem

Minimal or none

Minimal risk of morbidity from additional diagnostic testing or treatment

99203

99213

Low

Low

  • 2 or more self-limited or minor problems;

    or

  • 1 stable chronic illness;

    or

  • 1 acute, uncomplicated illness or injury

Limited

(Must meet the requirements of at least 1 of the 2 categories)

Category 1: Tests and documents

  • Any combination of 2 from the following:

    • Review of prior external note(s) from each unique source2;

    • review of the result(s) of each unique test2;

    • ordering of each unique test2

or

Category 2: Assessment requiring an independent historian(s)

(For the categories of independent interpretation of tests and discussion of management or test interpretation, see moderate or high)

Low risk of morbidity from additional diagnostic testing or treatment

99204

99214

Moderate

Moderate

  • 1 or more chronic illnesses with exacerbation, progression, or side effects of treatment;

    or

  • 2 or more stable chronic illnesses;

    or

  • 1 undiagnosed new problem with uncertain prognosis;

    or

  • 1 acute illness with systemic symptoms;

    or

  • 1 acute complicated injury

Moderate

(Must meet the requirements of at least 1 out of 3 categories)

Category 1: Tests, documents, or independent historian(s)

  • Any combination of 3 from the following:

    • Review of prior external note(s) from each unique source2;

    • Review of the result(s) of each unique test2;

    • Ordering of each unique test2;

    • Assessment requiring an independent historian(s)

      or

      Category 2: Independent interpretation of tests

  • Independent interpretation of a test performed by another physician/other qualified healthcare professional (not separately reported);

    or

    Category 3: Discussion of management or test interpretation

  • Discussion of management or test interpretation with external physician/other qualified healthcare professional\appropriate source (not separately reported)

Moderate risk of morbidity from additional diagnostic testing or treatment

Examples only:

  • Prescription drug management

  • Decision regarding minor surgery with identified patient or procedure risk factors

  • Decision regarding elective major surgery without identified patient or procedure risk factors

  • Diagnosis or treatment significantly limited by social determinants of health

99205

99215

High

High

  • 1 or more chronic illnesses with severe exacerbation, progression, or side effects of treatment;

    or

  • 1 acute or chronic illness or injury that poses a threat to life or bodily function

Extensive

(Must meet the requirements of at least 2 out of 3 categories)

Category 1: Tests, documents, or independent historian(s)

  • Any combination of 3 from the following:

    • Review of prior external note(s) from each unique source2;

    • Review of the result(s) of each unique test2;

    • Ordering of each unique test2;

    • Assessment requiring an independent historian(s)

      or

      Category 2: Independent interpretation of tests

  • Independent interpretation of a test performed by another physician/other qualified healthcare professional (not separately reported);

    or

    Category 3: Discussion of management or test interpretation

  • Discussion of management or test interpretation with external physician/other qualified healthcare professional/appropriate source (not separately reported)

High risk of morbidity from additional diagnostic testing or treatment

Examples only:

  • Drug therapy requiring intensive monitoring for toxicity

  • Decision regarding elective major surgery with identified patient or procedure risk factors

  • Decision regarding emergency major surgery

  • Decision regarding hospitalization

  • Decision not to resuscitate or to de- escalate care because of poor prognosis

1 Level of MDM is based on two out of three "Elements of Medical Decision Making."

2 Each unique test, order, or document contributes to the combination of two or combination of three in Category 1.

Finding Additional Information

This section also includes the following topics: