Coding Cheat Sheet (Pages 1-2/3) Prepared by: Raymond Tsai, R1, UCLAFamily Medicine Last updated 3/18/14 Evaluation and Management (E&M

) Codes Problem Based New Patients (all 3 components must be satisfied) History Exam* Medical Decision Making (need 2), this is the most (need Chief Complaint + all 3) ambiguous area, below is categories of risk mostly You can do different HPI ROS PFSH # of dx Data Risk levels of exam on just 1
system but details vary


99201 (NL1) 99202 (NL2)

Brief –(1-3 elements) N/A N/A

1-5 elements in at least 1 system (See below)

Straightforward Straightforward
Minimal (1) N/A or Minimal (lab draw, EKG/EEG, UA, u/s, Echo, CXR) Minimal (RICE)


Time w/ >50% spent counseling 10 minutes 20 minutes

Expanded problem-focused
Brief Problem Pertinent (only if in CC) N/A

Expanded problem-focused
At least 6 elements in at least 1 system

Or 30 minutes

99203 (NL3)

Extended (4+, or status of 3 chronic) Extended (additional 29 systems) Pertinent (at least 1)

At least 2 elements in at least 6 systems Limited (2+ minor, 1 stable or simple acute)

Limited (Tests not under stress, PFT, superficial biopsy, arterial puncture, barium) Low (OTC drugs, low risk prescriptions, minor surgery with no risk, PTOT, IV)


99204 (NL4)

Extended Complete (all systems, at least 10) Complete (one item in 2/3 areas)

At least two elements in at least 9 systems Multiple (1+ chronic with mild exacerbation, 2_ stable, 1 unknown, acute with system or complicated) Extensive (1+ chronic with severe exacerbation, abrupt change in neuro, acute life threatening)

Moderate (tests uder stress, endoscopies, incisional biopsy, LP, thoracentesis) Moderate (minor surgery with risk, elective major surgery with no risk, prescription w/ side effect management) High (elective major surgery, drugs needing monitoring, parenteral controlled subs)

45 minutes Or

99205 (NL5)

(same as above)

(same as above)

Extensive (CV imaging with risk, endoscopies with risk)

60 minutes Or

HPI Elements (should not be present in a preventive visit) 1) Location; 2) Quality; 3) Severity; 4) Duration; 5) Timing; 6) Context; 7) Modifying factors; 8) Associated signs and symptoms ROS Elements 1) Constitutional; 2) Eyes; 3) Ears, Nose, Mouth, Throat; 4) Cardiovascular; 5) Respiratory; 6) Gastrointestinal; 7) Genitourinary; 8) Musculoskeletal; 9) Integumentary (skin and/or breast); 10) Neurological; 11) Psychiatric; 12) Endocrine; 13) Hematologic/Lymphatic; 14) Allergic/Immunologic (accessed last Feb 5, 2014)

Problem Based for Established Patients (2/3 components must be satisfied) – Seen patient within last 3 years (> 3 years = new patient) History Exam Medical Decision Making Or Time w/ >50% spent counseling 99211 (EL1) N/A N/A N/A Or 5 minutes 99212 (EL2) Problem-focused Problem-focused Straightforward Or 10 minutes Expanded problem-focused Expanded problem-focused 99213 (EL3) Low Or 15 minutes 99214 (EL4) Detailed Detailed Moderate Or 25 minutes 99215 (EL5) Comprehensive Comprehensive High Or 40 minutes Preventive Visit Codes (Comp history and exam) Age New Established <1 year 99381 99391 1-4 99382 99392 5-11 99383 99393 12-17 99384 99394 18-39 99385 99395 40-64 99386 99396 65+ 99387 99397  Note Medi-cal will not cover preventive care for 40-65+ (18-39yo ok per ACA)  ICD-9 codes must correspond: V70.0 for males, V72.31 female, V20.2 up to 17 years Preventive Visit Codes (Medicare) Type of visit Initial visit in first year in medicare Initial visit if past 1st year Any subsequent visit ECG (add seperately) Code G0402 G0438 G0439 G0366

Medicare G0402/G0438 elements Comprehensive review of med hx, sochx, and famhx; 2) review of risk factors of depression; 3) review of functional ability and level of safety; 4) focused physical (weight, height, gp, and visual acuity are only reqs); 5) ECG with interpretation; 6) Brief education, counseling, and referral to address any issues; 7) brief education, counseling and referral with a written plan for preventive services

Coding Immunizations (Covered by Medicare) Vaccine ICD 9 Flu V04.81 (V06.6 w/ pneumo) Pneumocococcal V03.82 (V06.6 w/ flu) Hepatitis B V05.3

Coding Immunizations (Other) Vaccine ICD9 Vaccine Hep A V05.3 MMR Pediarix V06.8 Hib Kinrix V06.3 DTaP or Tdap

ICD9 V06.4 V03.81 V06.1

Vaccine HPV

ICD9 V04.89

Important Modifiers 1) GC – attending present (Must use this for Medicare in first 6 months) 2) GE – No attending 3) 25 : If you use more than 1 CPT/E&M/Diagnosis (i.e. Physical with specific problems, or office visit for chronic conditions and wart removal) 4) 59: Similar idea to 25, but for procedures 5) 24: Unrelated evaluation and management service by same physician during post-op period, 10 days for what we’d do (say 3 days after excision of benign skin lesion you see patient for HTN), use modifier otherwise second visit doesn’t count. If service occurs on same day, use modifier 25 6) 53: d/c’d procedure, if you start, and then decide too risky to perform, can get reimbursed for some of it with this modifier Pre-op clearance: Bill as consultation (E&M 99241 – 99245). Include referring surgeon, ICD-9 diagnosis for reason patient is having surgery, AND one of: V72.81 (cv exam), V72.82 (resp exam), V72.83 (other), or V72.84 (unspecified). 99243 requires detailed hx, detailed exam, low med decision making.

Coding Cheat Sheet (Pages 3/3) Prepared by: Raymond Tsai, R1, UCLAFamily Medicine Last updated 3/18/14 Physical Exam Components
Constitutional Eyes                                      Lymphatic (2 or more areas)  MSK   Measurement of any 3/7 vitals: 1) sitting or standing bp, 2) supine bp, 3) pulse, 4) respiration, 5) temp, 6) height, 7) weight General appearance (development, nutrition, body habitus, deformities, attention to grooming) Inspect conjunctivae and lids PERRL Optic discs (size, C/D ratio, appearance), and posterior segments (vessel changes, exudates, hemorrhages) External inspection of ears and nose (overall, scars, lesions, masses) Otoscopic exam (external canal and TM) Assessment of hearing Nasal mucosa, septum and turbinates Lips, teeth and gums Oropharynx (oral mucosa, salivary glands, hard and soft palates, tongue, tonsils, and posterior pharynx) Examination (masses, overall appearance, symmetry, tracheal position, crepitus) Thyroid (enlargement, tenderness, mass) Effort Percussion Palpation (fremitus) Auscultation Palpation  Femoral arteries Auscultation  Pedal pulses Carotid arteries  Extremities for edema and or varicosities Abdominal aorta Inspection of breasts Palpation of breasts and axillae Masses or tenderness Liver and spleen Presence or absence of hernia Examination (when indicated) of anus, perineum and rectum, sphincter tone, presence of hemorrhoids, rectal masses FOBT when indicated Male: Scrotal contents Penis DRE Female: (with or without specimen for smears/cultures) External and vagina (appearance, hair, lesions, discharge, pelvic support, cystocele, rectocele) Urethra (masses, tenderness, scarring) Bladder (fullness, masses, tenderness) Cervix (general appearance, lesions, discharge) Uterus (size, contour, position, mobility, tenderness, consistency, descent or support) Adnexa/parametria 2 or more areas: Neck, axillae, groin, other Examination of gait and station Inspection and/or palpation of digits and nails (clubbing, cyanosis, inflammatory conditions, petechiae, ischemia, infections, nodes) Examination of joints, bones and muscles of one or more of the following six areas: 1) head and check; 2) spine, ribs and pelvis; 3) right upper extremity; 4) left upper extremity; 5) right lower extremity, and 6) left lower extremity with: Inspection and/or palpation with notation of presence of any misalignment, asymmetry, crepitation, defects, tenderness, masses, effusions ROM Stability Strength and tone noting atrophy or abnormal movements Inspection of skin and subcutaneous tissue Palpation Cranial nerves Deep tendon reflexes with notation of pathological reflexes (eg Babinski) Examination of sensation (eg by touch, pin, vibration, proprioception) Description of patient’s judgment and insight Brief assessment of mental status: Orientation to time, place and person Recent and remote memory Mood and affect

Ears, Nose, Mouth and Throat

Neck Respiratory


Chest (Breasts) GI (Abdomen)


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Skin Neurologic