Outpatient New/Consult

Evaluation & Management Outpatient & Inpatient Coding Quick Reference

Outpatient - New/Consult (3 out of 3: History, exam, and MDM must be same level or higher to reach a particular level)
Level / History
(All required) / Exam / Medical Decision-Making
(Need 2 out of 3) / Avg. Time
1 / Chief Complaint +
HPI: 1-3 elements / 1 body area or system / Diagnosis or Mgmt options: 1
Data Reviewed/Ordered: ≤1
Level of Risk: Minimal / New: 10
Consult: 15
2 / Chief Complaint +
HPI: 1-3 elements
ROS: 1 system pertinent to CC
PFSH: None / Affected area/organ system + 2 to 7 body areas or organ systems (1 element documented per area/system) / Diagnosis or Mgmt. Options: 1
Data Reviewed/Ordered: ≤1
Level of Risk: Minimal / New: 20
Consult: 30
3 / Chief Complaint +
HPI: 4 or more elements
ROS: 2 to 9 systems including 1 system pertinent to CC
PFSH: 1 / Affected area/organ system (has to have at least 3 elements documented) + 2 to 7 body areas or organ systems / Diagnosis or Mgmt. Options: 2
Data Reviewed/Ordered: 2
Level of Risk: Low / New: 30
Consult: 40
4 / Chief Complaint +
HPI: 4 or more elements
ROS: 10 systems including 1 system pertinent to CC
PFSH: 3 / 8 or more organ systems (thyroid exam can count as 1 system) / Diagnosis or Mgmt. Options: 3
Data Reviewed/Ordered: 3
Level of Risk: Moderate / New: 45
Consult: 60
5 / Chief Complaint +
HPI: 4 or more elements
ROS: 10 systems including 1 system pertinent to CC
PFSH: 3 / 8 or more organ systems (thyroid exam can count as 1 system) / Diagnosis or Mgmt. Options: ≥4
Data Reviewed/Ordered: ≥4
Level of Risk: High / New: 60
Consult: 80
Outpatient - Established (2 out of 3: History or exam and MDM must be same level or higher to reach a particular level)
Level / History
(All required) / Exam / Medical Decision-Making
(Need 2 out of 3) / Avg. Time
1 / Minimal problem that may not require presence of physician (Nurse visit)
2 / Chief Complaint +
HPI: 1-3 elements
ROS: None
PFSH: None / 1 body area or organ system / Diagnosis or Mgmt. Options: 1
Data Reviewed/Ordered: ≤1
Level of Risk: Minimal / 10
3 / Chief Complaint +
HPI: 1-3 elements
ROS: 1 system pertinent to CC
PFSH: None / Affected area/organ system + 2 to 7 body areas or organ systems (1 element documented per area/system) / Diagnosis or Mgmt. Options: 2
Data Reviewed/Ordered: 2
Level of Risk: Low / 15
4 / Chief Complaint +
HPI: 4 or more elements
ROS: 2 to 9 systems including 1 system pertinent to CC
PFSH: 1 / Affected area/organ system (has to have at least 3 elements documented) + 2 to 7 body areas or organ systems / Diagnosis or Mgmt. Options: 3
Data Reviewed/Ordered: 3
Level of Risk: Moderate / 25
5 / Chief Complaint +
HPI: 4 or more elements
ROS: 10 systems including 1 system pertinent to CC
PFSH: 2 / 8 or more organ systems (thyroid exam can count as 1 system) / Diagnosis or Mgmt. Options: ≥4
Data Reviewed/Ordered: ≥4
Level of Risk: High / 40
Inpatient - Initial Visit (3 out of 3: History, exam, and MDM must be same level or higher to reach a particular level)
Level / History
(All required) / Exam / Medical Decision-Making
(Need 2 out of 3) / Avg. Time
1 / Chief Complaint +
HPI: 4 or more elements
ROS: 2 to 9 systems including 1 system pertinent to CC
PFSH: 1 pertinent / Affected area/organ system (has to have at least 3 elements documented) + 2 to 7 body areas or organ systems / Diagnosis or Mgmt. Options: 1-2
Data Reviewed/Ordered: ≤1
Level of Risk: Minimal or Low / 30
2 / Chief Complaint +
HPI: 4 or more elements
ROS: 10 systems including 1 system pertinent to CC
PFSH: 3 / 8 or more organ systems (thyroid exam can count as 1 system) / Diagnosis or Mgmt. Options: 3
Data Reviewed/Ordered: 3
Level of Risk: Moderate / 50
3 / Chief Complaint +
HPI: 4 or more elements
ROS: 10 systems including 1 system pertinent to CC
PFSH: 3 / 8 or more organ systems (thyroid exam can count as 1 system) / Diagnosis or Mgmt. Options: ≥4
Data Reviewed/Ordered: ≥4
Level of Risk: High / 70
Inpatient - Subsequent Visit (2 out of 3: History or exam and MDM must be same level or higher to reach a particular level)
Level / History
(All required) / Exam / Medical Decision-Making
(Need 2 out of 3) / Avg. Time
1 / Chief Complaint +
HPI: 1-3 elements / 1 body area or system / Diagnosis or Mgmt. Options: 1-2
Data Reviewed/Ordered: ≤1
Level of Risk: Minimal or Low / 15
2 / Chief Complaint +
HPI: 1-3 elements
ROS: 1 system pertinent to CC
PFSH: None / Affected area/organ system + 2 to 7 body areas or organ systems (1 element documented per area/system) / Diagnosis or Mgmt. Options: 3
Data Reviewed/Ordered: 3
Level of Risk: Moderate / 25
3 / Chief Complaint +
HPI: 4 or more elements
ROS: 2 to 9 systems including 1 system pertinent to CC
PFSH: 1 / Affected area/organ system (has to have at least 3 elements documented) + 2 to 7 body areas or organ systems / Diagnosis or Mgmt. Options: ≥4
Data Reviewed/Ordered: ≥4
Level of Risk: High / 35
Inpatient - Consult (3 out of 3: History, exam, and MDM must be same level or higher to reach a particular level)
Level / History
(All required) / Exam / Medical Decision-Making
(Need 2 out of 3) / Avg. Time
1 / Chief Complaint +
HPI: 1-3 elements / 1 body area or system / Diagnosis or Mgmt. Options: 1-2
Data Reviewed/Ordered: ≤1
Level of Risk: Straightforward or Low / 20
2 / Chief Complaint +
HPI: 1-3 elements
ROS: 1 system pertinent to CC
PFSH: None / Affected area/organ system + 2 to 7 body areas or organ systems (1 element documented per area/system) / Diagnosis or Mgmt. Options: 1
Data Reviewed/Ordered: ≤1
Level of Risk: Minimal / 40
3 / Chief Complaint +
HPI: 4 or more elements
ROS: 2 to 9 systems including 1 system pertinent to CC
PFSH: 1 / Affected area/organ system (has to have at least 3 elements documented) + 2 to 7 body areas or organ systems / Diagnosis or Mgmt. Options: 2
Data Reviewed/Ordered: 2
Level of Risk: Low / 55
4 / Chief Complaint +
HPI: 4 or more elements
ROS: 10 systems including 1 system pertinent to CC
PFSH: 3 / 8 or more organ systems (thyroid exam can count as 1 system) / Diagnosis or Mgmt. Options: 3
Data Reviewed/Ordered: 3
Level of Risk: Moderate / 80
5 / Chief Complaint +
HPI: 4 or more elements
ROS: 10 systems including 1 system pertinent to CC
PFSH: 3 / 8 or more organ systems (thyroid exam can count as 1 system) / Diagnosis or Mgmt. Options: ≥4
Data Reviewed/Ordered: ≥4
Level of Risk: High / 110
Outpatient - ER (3 out of 3: History, exam, and MDM must be same level or higher to reach a particular level)
Level / History
(All required) / Exam / Medical Decision-Making
(Need 2 out of 3)
1 / Chief Complaint +
HPI: 1-3 elements / 1 body area or system / Diagnosis or Mgmt options: 1
Data Reviewed/Ordered: 1
Level of Risk: Minimal
2 / Chief Complaint +
HPI: 1-3 elements
ROS: 1 system pertinent to CC
PFSH: None / Affected area/organ system + 2 to 7 body areas or organ systems (1 element documented per area/system) / Diagnosis or Mgmt. Options: 2
Data Reviewed/Ordered: 2
Level of Risk: Low
3 / Chief Complaint +
HPI: 1-3 elements
ROS: 1 system pertinent to CC
PFSH: None / Affected area/organ system + 2 to 7 body areas or organ systems (1 element documented per area/system) / Diagnosis or Mgmt. Options: 3
Data Reviewed/Ordered: 3
Level of Risk: Moderate
4 / Chief Complaint +
HPI: 4 or more elements
ROS: 2 to 9 systems including 1 system pertinent to CC
PFSH: 1 / Affected area/organ system (has to have at least 3 elements documented) + 2 to 7 body areas or organ systems / Diagnosis or Mgmt. Options: 3
Data Reviewed/Ordered: 3
Level of Risk: Moderate
5 / Chief Complaint +
HPI: 4 or more elements
ROS: 10 systems including 1 system pertinent to CC
PFSH: 3 / 8 or more organ systems (thyroid exam can count as 1 system) / Diagnosis or Mgmt. Options: 4
Data Reviewed/Ordered: 4
Level of Risk: High

06/17/08