Risk of Complications/Morbidity/Mortality:

 New    99201**    99202    99203    99204    99205  
 Established    99211    99212    99213    99214    99215  
 Diagnoses or Management Problems        One Self-limited or minor problem    Two or more self-limited or minor problems One stable chronic condition Acute uncomplicated illness (e.g., allergic rhinitis, simple sprain    One or more chronic illnesses with complications Two or more stable chronic illnesses Undiagnosed new problem w/ uncertain prognoses Acute illness with systemic symptoms Acute complicated injury    One or more chronic illness withsevere complications Acute or chronic illness or injury that is life or limb threatening Abrupt change in neurologic status  
 Diagnostic Procedures        Lab X-ray EKG UA Ultrasound, etc Venipuncture KOH.    Physiologic tests not under stress Pulmonary Function Barium enema Arterial puncture Skin biopsies    Physiologic tests under stress – cardiac stress test Diagnostic endoscopies with no risk factors Deep needle or incisional biopsy Obtained fluid from body Cardiovascular imaging with contrast    Cardiovascular imaging with contrast Invasive diagnostic tests Cardiac electrophysiological tests Diagnostic endoscopies w/ identified risk factors Discography  
 Treatment of Management Options        Rest Gargles Elastic bandages Dressings    OTCs Minor surgery w/ no identified risk factors PT OT IVs without additives    Minor surgery with risk factors Elective major surgery – no risk factors Prescription drug management IV fluids with additives Closed fracture or dislocation treatment w/o manipulation Therapeutic nuclear medicine    Elective surgery with identified risk factors Emergency major surgery Parenteral controlled substances Drug treatment requiring intensive monitoring Decisions not to resuscitate or de-escalate care because of poor prognosis  

** For a new patient 99201, use the requirements for a new patient 99202 Coding Requirements: The highest level of risk in any one column determines the overall risk. If there is not an item in documented in each one of the Presenting Problem, Amount/Complexity of Data, and Risk of Complications/Morbidity/Mortality you, are not eligible for a level beyond 99202.