HIM 300 DB - E&M Study Guide.docx - NEW PATIENT(not...

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NEW PATIENT (not seen in the practice within the past 3 years) Requires documentation of all 3 components LEVEL HISTORY EXAM MEDICAL DECISION TIME* 99201 Problem Focused Chief complaint HPI: 1-3 elements ROS: N/A PFSH: N/A 1-5 elements from a single system. 1-5 elements from multiple systems. Straightforward 10 min 99202 Expanded problem focused Chief complaint HPI: 1-3 elements ROS: 1 PFSH: N/A 6 or more elements from a single system. 6 or more elements from multiple systems. Straightforward 20 min 99203 Detailed Chief complaint HPI: 4 or more elements OR 3 chronic or inactive conditions ROS: 2 to 9 PFSH: 1 9 elements from eye or psychiatric exam OR 12 elements from any other single system exam. 12 elements from 2 or more organ systems/body areas. Low complexity 30 min 99204 Comprehensive Chief complaint HPI: 4 or more elements OR 3 chronic or inactive conditions ROS: 10 PFSH: 3 All elements and 1 element from each listed organ system/body area.
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