e/m elements

Elements of Medical Decision Making
Number and Complexity of Problems Addressed (one element)
[checkbox name="99213" value="2 or more self-limited or minor problems|1 stable chronic illness|1 acute, uncomplicated illness or injury"]

[checkbox name="99214" value="1 or more chronic illnesses with exacerbation, progression, or side effects of treatment|2 or more stable chronic illnesses|1 undiagnosed new problem with uncertain prognosis|1 acute illness with systemic symptoms|1 acute complicated injury"]

[checkbox name="99215" value="1 or more chronic illnesses with severe exacerbation, progression, or side effects of treatment|1 acute or chronic illness or injury that poses a threat to life or bodily function"]



Amount and/or Complexity of Data to be Reviewed and Analyzed
Must meet at least one requirement:
[checkbox name="99213" value="Category 1: Tests and documents
• Any combination of 2 from the following:
• Review of prior external note(s) from each
unique source;
• review of the result(s) of each unique test*;
• ordering of each unique test*
|Category 2: Assessment requiring an independent
historian(s)"]
Must meet at least one category:
[checkbox name="99214" value="Category 1: Tests, documents, or independent
historian(s)
• Any combination of 3 from the following:
• Review of prior external note(s) from each
unique source;
• Review of the result(s) of each unique
test;
• Ordering of each unique test;
• Assessment requiring an independent
historian(s)
|Category 2: Independent interpretation of tests
• Independent interpretation of a test performed
by another physician/other qualified health
care professional (not separately reported)
|Category 3: Discussion of management or test
interpretation
• Discussion of management or test
interpretation with external physician or other
qualified health care professional or appropriate
source (not separately reported)"]
Must meet the requirements of at least 2 out of 3
categories:
[checkbox name="99215" value="Category 1: Tests, documents, or independent
historian
• Any combination of 3 from the following:
• Review of prior external note(s) from each
unique source*;
• Review of the result(s) of each unique test*;
• Ordering of each unique test*;
• Assessment requiring an independent
historian(s)
|Category 2: Independent interpretation of tests
• Independent interpretation of a test
performed by another physician/other
qualified health care professional (not
separately reported);
|Category 3: Discussion of management or test
interpretation
• Discussion of management or test
interpretation with external physician/other
qualified health care professional/appropriate
source (not separately reported)"]


Risk of Complications and/or Morbidity or Mortality of Patient Management
[checkbox name="99213" value="Low risk of morbidity from additional diagnostic testing or treatment"]
[checkbox name="99214" value="Moderate risk of morbidity from additional diagnostic testing or treatment
Examples only:
• Prescription drug management
• Decision regarding minor surgery with identified patient or procedure risk factors
• Decision regarding elective major surgery without identified patient or procedure risk factors
• Diagnosis or treatment significantly limited by social determinants of health"]
Risk of Complications and/or Morbidity or Mortality of Patient Management
[checkbox name="99215" value="High risk of morbidity from additional diagnostic 
testing or treatment Examples only:
• Drug therapy requiring intensive monitoring for toxicity
• Decision regarding elective major surgery with identified patient or procedure risk factors
• Decision regarding emergency major surgery
• Decision regarding hospitalization
• Decision not to resuscitate or to de-escalate care because of poor prognosis"]

[text name="Minutes spent with patient" default="minutes spent with patient"]