Established CPT code 99211, 99212, 99213, 99214, 99215 Requirements

Evaluation & management tips: Office or other outpatient services, established patient

Key points to remember

The key components (elements of service) of evaluation & management (E/M) services are:
1. History
2. Examination
3. Medical decision-making.

When billing office or other outpatient services for established patients, 2 of the 3 key components must be fully documented in order to bill (other than 99211). When counseling and/or coordination of care dominates (more than 50%) the physician/patient and/or family encounter (face-to-face time in the office or other outpatient setting), then time may be considered the key or controlling factor to qualify for a particular level of E/M services. The extent of such time must be documented in the medical record.


Current Procedural Terminology® (CPT) codes and requirements

99211 - 5 minutes (average)
• Patient presenting with minimal problems
• 3 components not required

99212 - 10 minutes (average)
• Problem focused history. Documentation needed:
• Chief complaint
• Brief history of present illness
• Problem focused examination. Documentation needed:
• Limited examination of the affected body area or organ system
• Medical decision making that is straightforward. Documentation needed (2 of 3 below must be met or exceeded):
• Minimal number of diagnoses or management options
• None or minimal amount and/or complexity of data to be reviewed
• Minimal risk of significant complications, morbidity and/or mortality

99213 - 15 minutes (average)
• Expanded problem focused history. Documentation needed:
• Chief complaint
• Brief history of present illness
• Problem pertinent review of systems
• Expanded problem focused examination. Documentation needed:
• Limited examination of the affected body area or organ system and any other symptomatic or related body area(s) or organ system(s)
• Medical decision making that is of low complexity. Documentation needed (2 of 3 below must be met or exceeded):
• Limited number of diagnoses or management options
• Limited amount and/or complexity of data to be reviewed
• Low risk of significant complications, morbidity and/or mortality

99214 - 25 minutes (average)
• Detailed history. Documentation needed:
• Chief complaint
• Extended history of present illness
• Extended review of systems
• Pertinent past, family and/or social history
• Detailed examination. Documentation needed:
• Extended examination of the affected body area(s) or organ system(s) and any other symptomatic or related body area(s) or organ system(s)
• Medical decision making that is of moderate complexity. Documentation needed (2 of 3 below must be met or exceeded):
• Multiple number of diagnoses or management options
• Moderate amount and/or complexity of data to be reviewed
• Moderate risk of significant complications, morbidity and/or mortality

99215 - 40 minutes (average)
• Comprehensive history. Documentation needed:
• Chief complaint
• Extended history of present illness
• Complete review of systems
• Complete past, family, and social history
• Comprehensive examination. Documentation needed:
• A general multi-system examination OR complete examination of single organ system and other symptomatic or related body area(s) or 8 or more organ system(s)
• Medical decision making that is of high complexity. Documentation needed (2 of 3 below must be met or exceeded):
• Extensive number of diagnoses or management options
• Extensive amount and/or complexity of data to be reviewed
• High risk of significant complications, morbidity and/or mortality