Accurate medical coding is crucial for healthcare providers to ensure proper reimbursement and compliance. Within the Current Procedural Terminology (CPT) framework, Levels Of Care Codinglevels of care coding, providing a clear understanding of the key components and documentation guidelines necessary for accurate code selection. Whether you are coding for outpatient, inpatient, or consultation services, mastering levels of care coding is essential for efficient and compliant medical billing practices.
To effectively utilize levels of care coding, it’s important to understand the foundational elements that dictate code selection. The CPT manual, published by the American Medical Association (AMA), provides detailed documentation guidelines for each level of service within various E&M categories. These categories are broadly divided into office/outpatient services, consultations (office, inpatient), emergency room services, and hospital visits (initial and subsequent). Each category, except for initial and subsequent hospital visits which have three levels, typically has five levels of coding, reflecting a spectrum of service complexity.
Key Components of Code Selection
Selecting the correct level of care code hinges on evaluating seven key components. While all are important, three are considered key components when determining the appropriate code level:
- History: The extent and depth of the patient’s medical history taken by the provider.
- Examination: The scope and detail of the physical examination performed.
- Medical Decision Making: The complexity of thought and analysis required to diagnose and manage the patient’s condition.
The other contributing factors include:
- Patient Status: Whether the patient is new or established.
- Nature of Presenting Problem: The severity and complexity of the patient’s condition.
- Counseling and Coordination of Care: The time and effort spent counseling the patient and coordinating their care with other providers.
- Time: The duration of the encounter with the patient (in some cases, time can be a determining factor).
For new patients and consultations, coding guidelines mandate that all three key components (History, Exam, and Medical Decision Making) must be met or exceeded to reach a specific code level. However, for established patients and subsequent visits, the requirements are slightly less stringent; only two out of the three key components need to be met or exceeded.
Navigating Code Selection Charts
To simplify the process of selecting the correct code based on levels of care coding, consider the following steps and utilize the charts provided:
- Identify the Category: Determine the appropriate E&M category (e.g., office/outpatient visit, inpatient consultation).
- Understand Key Component Requirements: Note whether the category requires two or three key components to be met or exceeded (this is usually indicated at the top of each category’s chart).
- Assess History, Exam, and Medical Decision Making Levels: For each key component, determine the level achieved based on documentation guidelines (as outlined in the tables below).
- Match Levels to Code: Compare the determined levels of History, Exam, and Medical Decision Making to the code selection charts. If a row in the chart aligns with your assessed levels (meeting the two or three component rule), the corresponding code is likely the correct choice.
- Prioritize Multiple Single-Component Matches: If you find several rows that each match only one key component level, identify the row that matches a second component level. The code associated with this row is generally the most appropriate.
Let’s delve deeper into each of the key components: History, Examination, and Medical Decision Making.
Determining the Level of HISTORY
The “History” component in levels of care coding refers to the depth of information gathered by the healthcare provider about the patient’s medical background and current condition. There are four recognized levels of history, each building upon the previous one in terms of detail and scope. The table below outlines these levels:
| Level | Type of History | CC | HPI | ROS | PFSH |
|---|---|---|---|---|---|
| 1 & 2 | Problem Focused | Yes | 1-3 elements | N/A | N/A |
| 3 | Expanded Problem Focused | Yes | 1-3 elements | 1 | N/A |
| 4 | Detailed | Yes | 4 elements | 2-9 | 1 element |
| 5 | Comprehensive | Yes | 4 or more | 10+ | 2 est. pt. / 3 new pt. |
Key Definitions:
- CC (Chief Complaint): The patient’s primary reason for seeking medical care, briefly stated in their own words.
- HPI (History of Present Illness): A detailed chronological description of the development of the patient’s present illness, from the first sign or symptom to the present. Elements of HPI include: Location, Quality, Severity, Duration, Timing, Context, Modifying factors, and Associated signs and symptoms.
- ROS (Review of Systems): An inventory of body systems to identify signs or symptoms the patient may be experiencing or has experienced in the past. The ten recognized systems are: Constitutional, Eyes, Ears, Nose, Mouth, Throat, Cardiovascular, Respiratory, Gastrointestinal, Genitourinary, Musculoskeletal, Integumentary, Neurological, Psychiatric, Endocrine, Hematologic/Lymphatic, Allergic/Immunologic.
- PFSH (Past, Family, Social History): Review of the patient’s past medical history, family medical history, and social history that is relevant to the presenting problem.
As you move from Problem Focused history to Comprehensive history, the requirements for HPI, ROS, and PFSH become increasingly demanding, reflecting a more in-depth and thorough patient history.
Determining the Level of EXAMINATION
The “Examination” component of levels of care coding evaluates the extent and comprehensiveness of the physical examination performed by the provider. Similar to history, examination levels are progressive, with each level requiring a more extensive assessment. The levels are defined as follows:
| Level | Type of Examination | Body Systems Examined |
|---|---|---|
| 1 & 2 | Problem Focused | One |
| 3 | Expanded Problem Focused | Affected area and related systems (up to seven) |
| 4 | Detailed | Seven |
| 5 | Comprehensive | Eight or more systems |
The number of body systems examined directly correlates with the level of examination. A Problem Focused exam is limited to a single body system or organ system related to the chief complaint. In contrast, a Comprehensive exam requires examination of eight or more organ systems, indicating a much broader and thorough assessment of the patient’s physical condition.
Determining the Complexity of MEDICAL DECISION MAKING
Medical Decision Making (MDM) is arguably the most critical key component in levels of care coding. It reflects the complexity of thought processes involved in diagnosing and managing a patient’s condition. MDM is assessed based on three factors:
| Level | Decision Making Complexity | Number of Diagnoses or Management Options | Amount and/or Complexity of Data to Review | Risk of Complications and/or Morbidity or Mortality |
|---|---|---|---|---|
| 1 & 2 | Straightforward | Minimal (1) | Minimal or None (1) | Minimal (1) |
| 3 | Low Complexity | Limited (2) | Limited (2) | Low (2) |
| 4 | Moderate Complexity | Multiple (3) | Moderate (3) | Moderate (3) |
| 5 | High Complexity | Extensive (4+) | Extensive (4+) | High (4) |
Three Key Factors of Medical Decision Making:
A. Number of Diagnoses or Management Options: This considers the possible diagnoses, management options, and the complexity of choosing the best course of action. It includes:
- Clinical impressions
- Differential diagnoses
- Referrals
- Changes in treatment plans
Scoring for Diagnoses and Management Options:
- Self-limiting/minor problem, stable, improved, worsening (patient): 1 point (maximum 2 points for multiple minor problems)
- Established problem, stable, improved, well-controlled/resolving or resolved: 1 point
- Established problem, worsening, failing to respond, inadequately controlled: 2 points
- New problem, no additional workup planned: 3 points (maximum 1 point for each new problem without planned workup)
- New problem with additional workup planned: 4 points
B. Amount and/or Complexity of Data to Be Reviewed: This assesses the volume and intricacy of medical information the provider must analyze to make informed decisions. It includes:
- Reviewing medical records
- Ordering and reviewing tests (labs, x-rays, etc.)
- Discussing test results with other physicians
- Independent review of tracings, specimens, or images
Scoring for Amount and Complexity of Data:
- Discuss tests with performing physician: 1 point
- Order/review labs/x-rays/tests from the medicine section of CPT: 1 point
- Decision to obtain old records/history from someone other than the patient: 1 point
- Independent review of tracings, specimens, or x-rays: 2 points
- Review/summarize old records/history from someone other than the patient: 2 points
C. Risk of Complications and/or Morbidity or Mortality: This factor evaluates the potential risks associated with the patient’s condition, diagnostic procedures, and management options. It considers the potential for adverse outcomes and the level of risk the patient faces.
Table of Risk Levels:
| Level of Risk | Presenting Problem(s) | Diagnostic Procedure(s) Ordered | Management Options Selected |
|---|---|---|---|
| Minimal | One self-limited or minor problem, e.g., cold, insect bite, tinea corporis | Laboratory tests requiring venipuncture, Chest x-rays, EKG/EEG, Urinalysis, Ultrasound (e.g., echocardiography), KOH prep | Rest, Gargles, Elastic bandages, Superficial dressings |
| Low | Two or more self-limited or minor problems, One stable chronic illness (e.g., well-controlled hypertension or non-insulin dependent diabetes, cataract, BPH), Acute uncomplicated illness or injury (e.g., cystitis, allergic rhinitis, simple sprain) | Physiologic tests not under stress (e.g., pulmonary function tests), Non-cardiovascular imaging studies with contrast (e.g., barium enema), Superficial needle biopsies, Clinical laboratory tests requiring arterial puncture, Skin biopsies | Over-the-counter drugs, Minor surgery with no identified risk factors, Physical therapy, IV fluids without additives |
| Moderate | One or more chronic illnesses with mild exacerbation, progression, or side effects of treatment, Two or more stable chronic illnesses, Undiagnosed new problem with uncertain prognosis (e.g., lump in breast), Acute illness with systemic symptoms (e.g., pyelonephritis, pneumonitis, colitis), Acute complicated injury (e.g., head injury with brief loss of consciousness) | Physiologic tests under stress (e.g., cardiac stress test, fetal contraction stress test), Diagnostic endoscopies with no identified risk factors, Deep needle or incisional biopsy, Cardiovascular imaging studies with contrast and no identified risk factors (e.g., arteriogram, cardiac catheterization), Obtain fluid from body cavity (e.g., lumbar puncture, thoracentesis, culdocentesis) | Minor surgery with identified risk factors, Elective major surgery (open, percutaneous or endoscopic) with no identified risk factors, Prescription drug management, Therapeutic nuclear medicine, IV fluids with additives, Closed treatment of fracture or dislocation without manipulation |
| High | One or more chronic illnesses with severe exacerbation, progression, or side effects of treatment, Acute or chronic illnesses or injuries that pose a threat to life or bodily function (e.g., multiple trauma, acute MI, pulmonary embolus, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness with potential threat to self or others, peritonitis, acute renal failure), An abrupt change in neurologic status (e.g., seizure, TIA, weakness, or sensory loss) | Cardiovascular imaging studies with contrast with identified risk factors, Cardiac electrophysiological tests, Diagnostic endoscopies with identified risk factors, Discography | Elective major surgery (open, percutaneous or endoscopic) with identified risk factors, Emergency major surgery (open, percutaneous or endoscopic), Parenteral controlled substances, Drug therapy requiring intensive monitoring for toxicity, Decision not to resuscitate or to deescalate care because of poor prognosis |
It’s important to note that the “Table of Risk” serves as a guideline and is not exhaustive. Clinical judgment is essential in determining the actual risk level for each patient encounter.
The overall level of MDM is determined by the highest level of risk in any one of the three categories (Diagnoses/Management Options, Data, or Risk). For example, if the number of diagnoses points to Moderate complexity, but the data reviewed is of Low complexity and the risk is High, the MDM level is considered High.
Outpatient and Office Coding Examples
To further clarify levels of care coding, let’s look at examples for outpatient and office settings. Remember that for initial outpatient visits and consultations, all three key components must meet or exceed the criteria for a given code level. For subsequent outpatient visits, only two of the three key components are required.
Outpatient/Office Consultation Codes (New or Established Patient – Requires 3 Key Components):
| History Level | Exam Level | Medical Decision Making Level | CPT Code |
|---|---|---|---|
| Problem Focused | Problem Focused | Straightforward | 99241 |
| Expanded Problem Focused | Expanded Problem Focused | Straightforward | 99242 |
| Detailed | Detailed | Low Complexity | 99243 |
| Comprehensive | Comprehensive | Moderate Complexity | 99244 |
| Comprehensive | Comprehensive | High Complexity | 99245 |
Initial Office/Outpatient Visit Codes (New Patient – Requires 3 Key Components):
| History Level | Exam Level | Medical Decision Making Level | CPT Code |
|---|---|---|---|
| Problem Focused | Problem Focused | Straightforward | 99201 |
| Expanded Problem Focused | Expanded Problem Focused | Straightforward | 99202 |
| Detailed | Detailed | Low Complexity | 99203 |
| Comprehensive | Comprehensive | Moderate Complexity | 99204 |
| Comprehensive | Comprehensive | High Complexity | 99205 |
Subsequent Office/Outpatient Visit Codes (Established Patient – Requires 2 of 3 Key Components):
| History Level | Exam Level | Medical Decision Making Level | CPT Code |
|---|---|---|---|
| Problem Focused | Problem Focused | Straightforward | 99212 |
| Expanded Problem Focused | Expanded Problem Focused | Low Complexity | 99213 |
| Detailed | Detailed | Moderate Complexity | 99214 |
| Comprehensive | Comprehensive | High Complexity | 99215 |
These tables provide a simplified overview. Always refer to the full CPT manual and official coding guidelines for complete and accurate information.
Inpatient Coding Examples
Coding for inpatient services follows similar principles of levels of care coding, but the specific code sets and requirements differ slightly. For initial inpatient consultations and visits, all three key components are required. Subsequent inpatient visits require only two of the three key components to be met or exceeded.
Inpatient Consultation Codes (New or Established Patient – Requires 3 Key Components):
| History Level | Exam Level | Medical Decision Making Level | CPT Code |
|---|---|---|---|
| Problem Focused | Problem Focused | Straightforward | 99251 |
| Expanded Problem Focused | Expanded Problem Focused | Straightforward | 99252 |
| Detailed | Detailed | Low Complexity | 99253 |
| Comprehensive | Comprehensive | Moderate Complexity | 99254 |
| Comprehensive | Comprehensive | High Complexity | 99255 |
Initial Inpatient Visit Codes (New or Established Patient – Requires 3 Key Components):
| History Level | Exam Level | Medical Decision Making Level | CPT Code |
|---|---|---|---|
| Detailed | Detailed | Straightforward or Low Complexity | 99221 |
| Comprehensive | Comprehensive | Moderate Complexity | 99222 |
| Comprehensive | Comprehensive | High Complexity | 99223 |
Subsequent Inpatient Visit Codes (Established Patient – Requires 2 of 3 Key Components):
| History Level | Exam Level | Medical Decision Making Level | CPT Code |
|---|---|---|---|
| Problem Focused | Problem Focused | Straightforward or Low Complexity | 99231 |
| Expanded Problem Focused | Expanded Problem Focused | Moderate Complexity | 99232 |
| Detailed | Detailed | High Complexity | 99233 |
Remember, accurate levels of care coding is essential for compliant and optimized medical billing. Always stay updated with the latest CPT guidelines and seek clarification when needed.
Conclusion
Mastering levels of care coding is fundamental for healthcare professionals involved in medical billing and coding. By understanding the key components of History, Examination, and Medical Decision Making, and by diligently applying the CPT guidelines, providers can ensure accurate and ethical coding practices. This guide provides a foundational understanding of these complex concepts. For further in-depth knowledge and specific coding scenarios, always refer to the official CPT manual and seek out continuing education in medical coding and billing. Accurate coding not only ensures proper reimbursement but also contributes to the integrity and efficiency of the healthcare system.
