2021 E&M Coding Tool Adapted from: Table 2 –CPT E/M Office RevisionsLevel of Medical Decision Making (MDM)

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TODAY’S PROBLEM LEVEL TODAY’S DATA LEVEL TODAY’S RISK LEVEL TODAY’S TIME TODAY’S VISIT

(Circle one) (Circle one) (Circle one) (Circle one)

TOTAL TIME
LEVEL: 2 3  4 5 LEVEL: 2 3  4 5 LEVEL: 2 3  4 5 ON DOS: ______________ LEVEL: 2 3  4 5

Number & Complexity Amount and/or Complexity of Data Risk Time Final Level assigned, based on
of problems addressed Each unique test, order, or document contributes to a of morbidity from additional See reverse side for time MDM or Total Time
combination of 2 or of 3 in Category 1 below. diagnostic testing or treatment calculation tool based on activities

LEVEL 2 LEVEL 2 LEVEL 2 LEVEL 2

2 1 self-limited or minor problem Minimal or none Minimal risk 15–29 mins NEW: 99202 ABOUT THIS TOOL
10–19 mins EST: 99212 This tool is a guide for leveling
LEVEL 3 LEVEL 3 One category required LEVEL 3 LEVEL 3 outpatient E&M services using
ཛྷ 2 or more self-limited or minor CATEGORY 1: Any 2 from the following: Low risk 30–44 mins NEW: 99203 Medical Decision Making (orange)
problems; or ཛྷ Review of prior external note(s) from each unique source; 20–29 mins EST: 99213 *OR* Time (blue). The reverse
ཛྷ 1 stable chronic illness; or ཛྷ Ordering of each unique test or may be used to assist with
3 ཛྷ 1 acute, uncomplicated illness ཛྷ Review of the result(s) of each unique test; capturing all applicable activities
or injury
CATEGORY 2: in the clinician’s time total.
ཛྷ Assessment requiring an independent historian(s)
For independent interpretation and discussion of management or test
interpretation, see Level 4 or 5.
NOTES:
LEVEL 4 LEVEL 4 One category required LEVEL 4 LEVEL 4
ཛྷ 1 or more chronic illnesses with CATEGORY 1: Any 3 from the following: Moderate Risk 45–59 mins NEW: 99204
exacerbation, progression, or side ཛྷ Review of prior external note(s) from each unique source; 30–39 mins EST: 99214
effects of treatment; or EXAMPLES ONLY:
ཛྷ Ordering of each unique test or
ཛྷ 2 or more stable chronic illnesses; or ཛྷ Prescription drug management
ཛྷ Review of the result(s) of each unique test;
ཛྷ 1 undiagnosed new problem with ཛྷ Decision regarding minor surgery with
4 ཛྷ Assessment requiring an independent historian(s) or identified patient or procedure risk
uncertain prognosis; or
CATEGORY 2: factors
ཛྷ 1 acute illness with systemic
symptoms; or ཛྷ Independent interpretation of test performed by another MD/ ཛྷ Decision regarding elective major
QHCP/appropriate source (not separately reported); or surgery without identified patient or
ཛྷ 1 acute complicated injury procedure risk factors
CATEGORY 3:
ཛྷ Discussion of management or test interpretation with external ཛྷ Diagnosis or treatment significantly
MD/QHCP/appropriate source (not separately reported) limited by social determinants of health

LEVEL 5 LEVEL 5 Two categories required LEVEL 5 LEVEL 5

ཛྷ 1 or more chronic illnesses with CATEGORY 1: Any 3 from the following: High Risk 60–74 mins NEW: 99205
severe exacerbation, progression, or ཛྷ Review of prior external note(s) from each unique source; 40–54 mins EST: 99215
side effects of treatment; or EXAMPLES ONLY:
ཛྷ Ordering of each unique test or
ཛྷ 1 acute or chronic illness or injury ཛྷ Drug therapy requiring intensive
ཛྷ Review of the result(s) of each unique test; monitoring for toxicity
that poses a threat to life or bodily
ཛྷ Assessment requiring an independent historian(s) or
5 function ཛྷ Decision re: elective major surgery with
CATEGORY 2: identified patient or procedure risk
ཛྷ Independent interpretation of test performed by another MD/ factors
QHCP (not separately reported); or ཛྷ Decision re: emergency major surgery
CATEGORY 3: ཛྷ Decision re: hospitalization
ཛྷ Discussion of management or test interp with external MD/ ཛྷ Decision not to resuscitate or to
QHCP/appropriate source (not separately reported) de-escalate care due to poor prognosis
2021 E&M Coding Tool
TIME REFERENCE

Include ALL minutes clinician New Patient Established Patient

Activities Time Spent (MINUTES) spent on patient on DOS
LEVEL 2
Pre-Visit 15–29 mins 99202 10–19 mins 99212
Reviewing notes, results, correspondence, reports
(Note sources, dates)
LEVEL 3
30–44 mins 99203 20–29 mins 99213
Other:
LEVEL 4
Visit 45–59 mins 99204 30–39 mins 99214
History from patient and others LEVEL 5
(Note sources)
60–74 mins 99205 40–54 mins 99215
History, examination, discussion, counseling, education, planning

Ordering, referrals, documenting

Planning, ordering, referrals

Other:

Post-Visit
Documenting

Reviewing and communicating results

Independent interpretation of tests (not separately billed)

Care coordination (not separately billed)

Other:
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TOTAL TIME ON DOS Email: [email protected]
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