Billing
CMS Requirements for Billing
| 99281 | 99282 | 99283 | 99284 | 99285 | |
| Level1 | Level 2 | Level 3 | Level 4 | Level 5 | |
| HPI | 1 of 8 | 1 of 8 | 1 of 8 | 4 of 8 | 4 of 8 |
| ROS | 0 | 1 | 1 | 2 | 10 |
| PMHx, FamHx, Social Hx | 0 | 0 | 0 | 1 | 2 |
| PE | 1 | 2 | 2 | 5 | 8 |
| MDM | Straight‐forward | Low Complexity | Moderate Complexity | Moderate Complexity | High Complexity |
History of Present Present Illness Illness (HPI)
- Location
- Severity
- Timing
- Modifying Factors
- Associated Associated Signs and Symptoms Symptoms
- Onset
- Quality
- Duration
Past Medical, Family, Family, Social History
- Past Medical
- Past Illnesses
- Major Injuries
- Surgical History
- Hospitalizations
- Immunizations
- Feeding/Dietary
- Family History
- Health Status
- Deaths
- Hereditary Diseases
- Social History
- Drug, etoh , tobacco
- Employment
- Marital Status
- Sexual History
Review of Systems
There are 14 organ systems recognized by CMS:[1]
- Constitutional
- Eyes
- Ears, Nose, Mouth and Throat
- Cardiovascular
- Respiratory
- Gastrointestinal
- Musculoskeletal
- Integumentary (skin and/or breast)
- Neurologic
- Psychiatric
- Endocrine
- Hematologic/Lymphatic
- Allergic/Immunologic
Physical Exam
CMS recognizes the following 14 systems as part of the physical exam:[2]
- Constitutional
- Eyes
- Ears, Nose, Mouth and Throat
- Neck
- Respiratory
- Cardiovascular
- Chest (Breasts)
- Gastrointestinal
- Genitourinary
- Lymphatic
- Musculoskeletal
- Skin
- Neurologic
- Psychiatric
Medical Decision Making (MDM)
MDM complexity can be increased by documenting the following things as applicable
- Discussing differentials
- Review labs as it relates to the case
- Independently review imaging
- Note discussions with consultants
- Note discussions of imaging/procedures with performing provider (radiology, GI, ENT, etc)
- Order prescription medications
CMS MDM example.
Multiple possible diagnoses for patient’s chest pain considered. After reviewing the patient’s medical record, lab and radiology results and discussing the case with the patient’s PMD, doubt PE as pulse oximetry normal and no tachypnea or tachycardia. Dissection unlikely as presentation not consistent with the diagnosis. ACS unlikely as normal EKG and no risk factors. Combination of infiltrate on CXR, fever and cough make pneumonia most likely diagnosis. Moderate risk of complications. Will treat with antibiotics and admit.
RVU For Level of Service[3]
- 99281 (Level 1) = 0.64 RVUs
- 99282 (Level 2) = 1.24 RVUs
- 99283 (Level 3) = 2.10 RVUs
- 99284 (Level 4) = 3.57 RVUs
- 99285 (Level 5) = 5.16 RVUs
- 99291 (Critical Care) = 8.19 RVUs 1st hr
- Critical Critical care can be coded when the total duration of time spent by a provider in providing critical care services to a critically ill or critically injured patient is at least 30 minutes, even if the time spent is not continuous.