LAV DESCRIPTION VERSION OF THE Expansion by AMA Effective January 1, 2023: 99202 - 99215 OFFICE/CLINIC BASED SERVICES

Level of Medical Decision Making (MDM} Note: The following is a modification of the original AMA MOM Chart. This chart has been modified to provide more general terms and also include more
specifications from the guidelines.

Elements of Medical Decision Making

Level of Service Risk of Complications and/or Morbidity or Mortality of
Code ( Based on 2 out of 3 Number and Complexity Work Performed & Analyzed During
Elements of MDM) the Encounter Patient Management
-OR-Time
of Problems Addressed Directions for this column are noted in each area of risk row. This column is the column that requires scoring. Choose the risk area with the highest score. NOTE: THIS COLUMN INCLUDES EXAMPLES ONLY!

99211 Services at th s level are provided by ancillary staff. *NOTE: /J ncillary staff and providers must be employed by the same TAX ID number to meet supervisior requirements
Neg11gio1e risK tnat 111ness, runct1ona1 1mpa1rment, or organ aamage will occur rrom tne
99202 Straigh tforward - or- M,·n,·mal · I or none
M"m1ma management options and/or treatment plan considered and/or established.
Minimal infers the typical work of the encounter, but no additional order, review, or otherwise classified work of theprovider to be categorized below
99212 ::���: �� - 29 I 99212 10 - 19 • l negligible or meager problem addressed Example ONLY:
>----+-----------+-----------------------+----------------------------------------------�•�.:0.ll.o_w_u.pY--8N,� _ ----------------------<
Low Limited Below average risk that illness, functional impairment, or organ
• 2 or more negligible or meager problem addressed; (Must meet the requirements of at least 1 ofthe 2 categories)
Low damage will occur from the management options and/or treatment
• or Category 1: Tests and documents (Work commonly associated with E&M services) plan considered and/or established.
-or- • 1 stable chronic problem addressed; • Documentation noting 2 of the following were performed:
99203 • Evaluate external records from an external provider (may not divide per test/per CPT); Examples ONLY:
or
o Example: Review of admission to the ED or IP since previous visit • Medications NOT requiring prescriptive authority
99213 Time: • 1 acute, direct or well-defined problem addressed or
• review of prior test result(s) per unique test, i.e. per CPT- except tests ordered by the rendering provider; • DME
99203: 30-44 injury; o Example: PCP reviews testing ordered and performed by the cardiologist • Physical Therapy
or
99213: 20-29 • ordering imaging, lab, psychometric, physiologic data testing per CPT • Consult/Referral without elaboration
• 1 stable, acute illness; o Example: If the 26 component is NOT billed by the provider- the order can be allowed. However, the
99243: 30 or • or order and independent interpretation could NOT be combined.
• 1 acute, direct or well-defined problem addressed or Category 2: Encounter including an additional historian(s)
injury requiring inpatient or observation admit *Documentation: Who is the historian, information historian provided, and best practices- why historian was required
Moderate Moderate Average risk that illness, functional 1mpa1rment, or organ aamage will
• 1 (or+) chronic complaint(s) that is not stable, or noted as (Must meet the requirements of at least 1 out of 3 categories) occur from the management options and/or treatment plan considered
Moderate progressing/worsening, or side effects of treatment; Category 1: Tests, documents, or independent historian(s) and/or established.
-or- • Any combination of 3 from the following: (REFER TO EXAMPLES ABOVE): Examples ONLY:
or • Evaluate external records from an external provider (may not divide per test/per CPT); • Initiation, continuation, discontinuation, modification of a
• 2 (or+) stable chronic problems addressed; • review of prior test result(s) per unique test, i.e. per CPT- except tests ordered by the rendering provider; medication that requires prescriptive authority
Time: or • ordering imaging, lab, psychometric, physiologic data testing per CPT; •
99204 Decision or consideration of a minor* procedure with documented
99204: 45-59 • 1 new problem undiagnosed potentially high risk;
or
• encounter including an additional historian(s) patient or procedure risk factors .
99214 99214: 30-39 or • Decision or consideration of a major* procedure without
• 1 acute complaint with unanticipated symptoms;
Category 2: Independent interpretation of tests
99244: 40
or • Rendering provider documents an independent interpretation of a test that has been or will be formally read
•
documented patient or procedure risk factors.
Documentation indicates that the patients economic or social
and billed by another provider. A formal report is NOT required (not separately reported);
• 1 acute complex injury o Example: Provider request Chest Xray- reviews the images and provides an interpretation within the conditions impact appropriately treating or diagnosing the patient
E&M at the time of service that impacts care. Radiology will provide an over-read at a later time which • Documentation indicates a consult/referral is required for
or will be billed.
consideration of an average risk/moderate risk management
Category 3: Discussion of management or test interpretation option
• Documentation identifying direct dialogue between external providers or other appropriate sources (not
separately reportable) regarding the management or test interpretation of the patient (asynchronous allowed) *AMA: Minor and Major are at the discretion of the provider as documented
o Example: Provider makes the decision to send the patient to the ED. The provider calls the ED provider to discuss *CMS: Minor 0-10 global I Major 90 day global

High High Extensive (REFER TO EXAMPLES ABOVE): Above average risk that illness, functional impairment, or organ
• 1 (or +) chronic problem(s) severely triggered, (Must meet the requirements of at least 2 out of 3 categories) damage will occur from the management options and/or treatment
progression, or side effects of treatment; plan considered and/or established.
-or-
or Category 1: Tests, documents, or independent historian(s)
Examples ONLY:
99205 Time: • 1 acute or chronic problem or injury that places danger/ • Any combination of 3 from the following: • Long/short term intensive monitoring to prevent toxicity (NOT
risk to life or bodily function • Evaluate external records from an external provider (may not divide per test/per CPT);
monitoring efficacy)
99215 99205: 60-74 • review of prior test result(s) per unique test, i.e. per CPT- except tests ordered by the rendering provider;
• Decision or consideration of a major* procedure with documented
99215: 40-54 • ordering imaging, lab, psychometric, physiologic data testing per CPT;
99245: 55 patient or procedure risk factors.
• encounter including an additional historian(s) • Decision or consideration of an major* surgery performed with
or minimal delay/immediate
Category 2: Independent interpretation of tests • Decision or consideration for hospitalization or alternative levels
• Rendering provider documents an independent interpretation of a test that has been or will be formally read
of care
and billed by another provider. A formal report is NOT required (not separately reported);
• Documentation of election or consideration of DNR status and/or
or de-escalate due to a low chance of recovery
Category 3: Discussion of management or test interpretation • Administration of controlled substance via IM, IV, or SubQ
• Documentation identifying direct dialogue between external providers or other appropriate sources (not
*AMA: Minor and Major are at the discretion of the provider as documented
separately reportable) regarding the management or test interpretation of the patient (asynchronous allowed) *CMS: Minor 0-10 global I Major 90 day global

This chart is a COMPLIMENTARY download from NAMAS. For a copy of this MOM chart, contact NAMAS by email at [email protected] or at 877-418-5564
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 Vignettes for 2021 Documentation Guidelines
*NOTE* Vignettes are recommendations only and documentation criteria is required to support the appropriate level of service.

Minimal Complexity Low Complexity & Moderate Complexity High Complexity &
& Risk Encounter Risk Encounter & Risk Encounter Risk Encounter
Patient presents for follow up of
Patient present post Patient w/chronic problem
Patient with chronic stable DM. Sugars today are 565 and the
global/surgical and is placed on a new RX medication
problem presents and provider makes the decision to send
recovering well and is last visit. This visit, it is noted
medication is refilled. the patient to the ED. The patient
discharged from care to follow they are not at treatment goals,
refuses. The provider documents
up as needed in the future. continue current plan.
that they recommended advanced
care, but the patient refused. The
Patient presents with a new documentation also included the
Patient presents with common Patient presents with ear pain
problem-workup for diagnose is risks to the patient for not receiving
cold and is told to return if which is diagnosed as OM. No
required, but the suspected problem advanced care in their condition.
symptoms worsen and provided systemic symptoms are noted.
will have substantial duration and
reassurances. The patient is prescribed an
PT's function will be limited. The PT
antibiotic. Patient presents w/asthma
is provided RX for pain management
exacerbation & possible URI, PT is
retracting/audible wheezes. O2
Patient is seen and the decision is Patient presents with acute provided, first nebulizer, minimal
made to perform a minor procedure. onset of respiratory complaints. improvement, second nebulizer, air
However an additional chronic The patient, diagnosed with URI flow returns. RX provided, and
problem is also addressed and OTC is having labored breathing. emergency protocols revisited.
anti-inflammatory recommended. Patient is given an antibiotic. ED visit avoided- and should be
documented- if it was considered.

In order to make the most out of these vignettes,

ABOUT THESE VIGNETTES: These vignettes have been designed to offer
examples of patient care, utilizing Column 1 and consider a challenge-
It is important to understand Column 3 of the MDM chart, it requires that the Take these vignettes and the AMA MDM chart, and
documentation include the complexity and risk analyze the condition to the MDM chart. Identify
the associated with these categories to support the why each, utilizing Column 1 & 3 support the levels
DOCUMENTATION level of service. identified above.

matters Each example in the vignette has been selected to Have a question?
try and provide the most common scenarios Contact us: [email protected]
regardless of specialty. 1-877-418-5564