Risk of Complications/Morbidity/Mortality:
|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.