Coding 99212 vs. 992131
  99212 99213
HISTORY Problem-focused Expanded problem-focused
  CC: yes
HPI: brief (1-3 elements)
PFSH: none
ROS: none		 CC: yes
HPI: brief (1–3 elements)
PFSH: none
ROS: 1 system
EXAM2 Problem-focused Expanded problem-focused
  1 component of affected body area/organ system. 1 component of affected body area/organ system, plus an additional 1-7 symptomatic-related body areas/organ systems.
MEDICAL DECISION MAKING3 Straightforward Low complexity
Diagnosis Diagnosis/management options:
Minimal
Need 1 point
Examples:

  • One self-limited/minor problem (1 point).

  • One stable established problem (1 point).

 Diagnosis/management options:
Limited
Need 2 points
Examples:

  • One self-limited/minor problem AND one stable established problem (2 points).

  • One established problem, worsening (2 points).
Data Amount/complexity of data:
Minimal
Need 1 point
Examples:

  • Review and/or order lab, radiology or medical test (1 point).

  • Discuss results with testing physician (1 point).

  • Obtain old records (1 point).

 Amount/complexity of data:
Limited
Need 2 points
Examples:

  • Review and/or order lab test (1 point).

  • Review and/or order radiology test (1 point).

  • Review and/or order medical test (1 point).

  • Independently interpret specimen/imaging/tracing (2 points).

  • Summarize review of old records/additional history (2 points).
Risk4 Level of risk: Minimal Level of risk: Low
  Examples: Examples:
Presenting problem

  • One self-limited or minor problem, e.g., cold, insect bite, tinea corporis.

  • Two or more self-limited or minor problems.

  • One stable chronic illness, e.g., controlled hypertension, diabetes mellitus, benign prostatic hyperplasia.

  • One acute uncomplicated illness or injury, e.g., cystitis, allergic rhinitis, simple sprain.
Diagnostic procedures

  • Lab with venous puncture.

  • Chest X-ray.

  • ECG.

  • Urinalysis.

  • Ultrasound.

  • Wet prep.

  • Physiologic tests not under stress, e.g., pulmonary function tests.

  • Non-CV imaging studies with contrast, e.g., barium enema.

  • Superficial needle biopsies.

  • Lab tests with arterial puncture.

  • Skin biopsies.
Management options

  • Rest.

  • Gargles.

  • Elastic bandages.

  • Superficial dressings.

  • OTC drugs.

  • Minor surgery with no identified risk factors.

  • Physical or occupational therapy.

  • IV fluids without additives.