Medical review - physical exam for office visit

Physical Exam

Organ Systems and Body Parts are both included in the physical exam. An item can be included in either an Organ System or a Body Part, but the same item cannot be in both. One point is achieved when a System or Part is identified. Each System or Part is counted only once.

Body Parts:
1. Head (this includes sinuses)
2. Neck
3. Chest (including Breasts & Axillae)
4. Abdomen
5. Genitalia (Groin & Buttocks)
6. Back & Spine
7. Each Extremity (each extremity is counted once - up to 4 points in total)

Organ Systems: 

 1. Constitutional
One vital sign and general appearance of patient (Vitals taken by a MA should be dictated into the note. This acknowledges that they were reviewed.)

2. Eyes
conjunctivae & lids; PERRLA, EOMs intact; optic discs

3. Ears, Nose, Mouth, Throat
external ears and nose; ears and TM’s; hearing; nasal mucosa; septum & turbinates; lips, teeth, & gums; oropharynx

4. Cardiovascular

palpitation of heart; auscultation; carotids; abdominal aorta; femoral pulses; pedal pulses; extremities for edema &/or varicosities

5. Respiratory

respiratory effort; percussion; palpation; auscultation

6. Gastrointestinal
masses, tenderness; liver & spleen; hernia; anus, perineum & rectum; occult test

7. Genitourinary
Male: scrotal contents; penis; prostate gland
Female: external genitalia; urethra; bladder; cervix; uterus; adnexa/parametric


8. Musculoskeletal
gait & station; digit & nails; joints, bones, muscles of at least 1 area Extremities: left upper, right upper, left lower; tight lower, head, neck, spine, ribs, pelvis (exam should include inspection/palpation, ROM, stability, strength, tone)

9. Skin
inspection; palpation

10. Neuralgic
cranial nerves; reflexes; sensation

11. Psychiatric
Judgment & insight; orientation of time, place & person; memory; mood & affect

12. Hematologic/Lymphatic/Immunologic
lymph nodes in 2 or more areas: neck, axillary, groin, other

Coding Requirements:
                      Level 99202, 99212 requires at least 1
                      Level 99203, 99213 requires at least 2
                      Level 99204, 99214 requires at least 5
                      Level 99205, 99215 requires at least 9

Office visit - Risk of Complications/Morbidity/Mortality:

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.

New or Established patient - Past, Family, and Social History:

Past, Family, and Social History: 

Past History: 
Patient's past experiences with illnesses, operations, injuries, treatments, medications, or allergies relevant to the condition being treated. (All medications and allergies are relevant.)

Family History:
Diseases which are hereditary, or put the patient at risk. .

Social History:
Past or current activities that are appropriate for patient (i.e. smoking - active or passive, drug use, alcohol use).

Coding Requirements:

New Patients
       Level 99202 require none
       Level 99203 require none
      Level 99204 require at least 1
      Level 99205 require at least 3

Established Patients
       Level 99212 requires none
       Level 99213 requires none
       Level 99214 requires at least 1
       Level 99215 requires at least 2

If the patient is unable to provide this information, document this fact in the chart and the reason. You will then be able to use the maximum number available.

Billing 99202 - 99204 or 99213 - 99214 New or Established patient - History of present illness

History of Present Illness:

There are 8 factors that can be addressed:

1. Location – where is the problem on/in the body [LLL quadrant, throat, head]
2. Quality – a word that describes the problem [Sharp, dull, dry, wet, hot, cold, clammy, burning]
3. Severity – how is the problem rated [Mild, moderate, severe, excruciating, worsening Pain scale (4/10)]
4. Duration - how long do the symptoms last? [Constant, intermittent, seconds, minutes, hours, days, weeks, months]
5. Timing – when did symptoms begin? [One week ago, 3 hours ago]
6. Context – what was the patient doing that caused the symptoms? [Walking, standing, sitting, chewing, after eating]
7. Modifying Factors – what has been done to alleviate or worsen the symptoms? [OTCs, medications, rest, elevation, change in diet]
8. Associated Signs and Symptoms – conditions that go with the presenting problem [Headache, nausea, diarrhea, palpitations]

Coding Requirements:

Level 99202, 99212 require at least 1
Level 99203, 99213 require at least 1
Level 99204, 99214 require at least 4 (or status of at least 3 chronic health conditions)*
Level 99205, 99215 require at least 4 (or status of at least 3 chronic health conditions)*

If patient is unable to provide the history, document this and the reason they are unable to. This will allow you to consider the maximum number.

*The must be a rational for the reason of the status, such as lab work with specific information or symptom frequency.

How to determine new and Established patient - Chief complaint

Are They a New or Established Patient? 

It is important to determine this at the beginning since it will help you determine requirements in your documentation.

They are a new patient if they have not seen a medical provider at Family Health Center in the last 3 years. This could be in Urgent Care, School-Based Health Centers, Elm Park, Webster Square or on a Team. This does not include Dental or Mental Health. If you have a chart with no notation, it is wise to ask the patient, since documentation may not have made it into the chart before you saw the patient.

Chief Complaint: 
This is the reason the patient is there to see the provider. There may be more than one reason. If it is for a follow-up visit, it must state the condition that is being followed: i.e., follow-up on asthma, diabetes, rash, etc. “Routine” is not an appropriate statement.

Parts of Documentation: 
1. History of Present Illness Review of Systems Past, Family and Social History
2. Physical Exam
3. Presenting Problem to Treating Provider Amount and/or Complexity of Data to be Reviewed Risk of Complications/Morbidity/Mortality

CPT code 99202 and 99212 - Review of system

procedure   Code 99202  OFFICE OUTPATIENT NEW 20 MINUTES

Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: an expanded problem focused history; an expanded problem focused examination; and straightforward medical decision making.

Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.

 Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 20 minutes face-to-face with the patient and/or family.


99202 Expanded Problem Focused 20 MIn


procedure  Code Descriptor Work RVU RVU RVU RVU Total RVU Total RVU

99202 Office Visit, New Pt 0.88 0.80 0.31 0.05 1.73 1.24

Can medical doctor bill Procedure  code 99202 & 94150 

Ans : Yes.

Note : Evaluation and Management Procedure -4 code 99202 (office visit, new patient, level 2) may be billed by a respiratory care practitioner once every three years; however, the recipient must not have been seen for any reason during the preceding three-year period by the same respiratory care practitioner.  Procedure -4 code 99212 (office visit, established patient, level 2) may be billed by a respiratory care practitioner once in six months by the same provider, for the same recipient, with authorization.

Can we bill Procedure  99202 and 99381 on Same day.

No, we cant because both are E & M code and one code only eligible to pay.


Evaluation and Management Codes


In a health department environment, a limited range of E & M codes would be submitted including 99201, 99202, 99203, 99211, 99212 and 99213. These codes are used for new patients (99201, 99202, 99203) and established patients (99211, 99212, 99213) when treated in an office and/or outpatient setting.

There also are preventive medicine codes that may be used to report the preventive medical evaluation of infants, children and adults. These visits will not have a presenting problem as they are “well” preventive visits. These codes are defined as a new or established patient and by age. Health Care Reform Preventive Health Benefits with Recommended Procedure  and Diagnosis Codes The codes for new patients are 99381-99387 and for established patients 99391- 99397. If the age of the patient does not match the age described in the code,  the claim will be rejected.

According to AMA Procedure and BCBSKS definitions, a new patient is a patient who hasn’t been seen for three or more years in a practice. An established patient is a patient who has been treated in the practice within the past three years.

When a patient makes an appointment, a reason for the encounter needs to be established. Per AMA Procedure , a “concise statement describing the symptom, problem, condition, diagnosis or other factor that is the reason for the encounter, usually stated in the patient’s words.”

At this point a diagnosis is established for the encounter. The reason for the encounter will be assigned an ICD-9 code to correlate with the AMA Procedure  code.

An ICD-9 code defines what prompted the encounter and the AMA Procedure ® code  defines what service was performed during the encounter.

The different levels of office visits are determined by six of seven components:

• History
• Examination
• Medical decision making
• Counseling
• Coordination of care
• Nature of presenting problem
• Time *

*In a health department setting, time probably would not be a factor in determining the level of E & M code.

However, the first three components – history, examination, medical decision making – are key components to selecting the level of E & M code. The extent of the history is determined by the clinical opinion of the performing  provider based on the patient’s complaints. The levels of history most likely to be seen in a health department setting are problem and expanded problem focused.

Per AMA Procedure guidelines they are defined as follows:

• Problem focused: chief complaint; brief history of present illness or problem.

• Expanded problem focused: chief complaint; brief history of present illness; problem pertinent system review.


• Detailed: chief complaint; extended history of present illness; problem pertinent system review extended to include a review of a limited number of additional systems; pertinent past, family, and/or social history directly related to the patient’s problems.

The next step is to decide on the appropriate examination level. Once again, this is determined by the performing provider. The level of examinations which would be expected to be seen in a health department setting is as follows per Procedure guidelines:

• Problem focused: a limited examination of the affected body area or organ system.

• Expanded problem focused: a limited examination of the affected body area or organ system and other symptomatic or related organ system(s).

• Detailed: an extended examination of the affected body area(s) and other symptomatic or related organ system(s).

The third key component is to determine the complexity of the medical decision making as determined by the performing provider. In a health department setting the two levels of medical decision making that would routinely be seen are  straightforward and low complexity.

• Straightforward: minimal number of diagnoses or management options; minimal or no amount and/or complexity of data to be reviewed; minimal risk of complications and/or morbidity or mortality would be involved.

• Low complexity: limited number of diagnoses or management options; limited amount and/or complexity of data to be reviewed; low risk of complications and/or morbidity or mortality would be involved.

After selecting the level of office visit that is to be submitted for reimbursement, it needs to be determined what additional services, if any, were provided to the patient, i.e., injections and or immunizations.


The CMS HCPCS code list would be used to locate drugs to supplement the AMA Procedure ®codes as the second level of the coding system. After selecting the level of office visit to be submitted, and if applicable, a second level (HCPCS) code; a diagnosis code must be assigned. Per AMA Procedure  guidelines, the primary diagnosis is what prompted the encounter as described in the patient's own words.


Per the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) guidelines, the primary diagnosis is what prompted the encounter as described in the patient’s own words.

Review of Systems: 

These are based on questions that the provider asks the patient.
At least one item must come from a specific area for that area to be included. If patient’s condition prevents them from doing a review of system (a physical or mental condition), it should be stated so and then Review of Systems will receive the necessary credit.

This generally starts with “Patient denies…” or “Patient states….”
1. Constitution – general opinion of health
2. Eyes
3. Ears, Nose, Throat, Mouth
4. Cardiovascular
5. Respiratory
6. Gastrointestinal
7. Genitourinary
8. Musculoskeletal
9. Integumentary (and/or Breasts)
10. Neurological
11. Psychiatric
12. Endocrine
13. Hematologic/Lymphatic
14. Allergic/Immunologic

Statements such as “ROS done” or All ROS negative” are inappropriate.

Coding Requirements:

               Level 99202, 99212 requires none
              Level 99203, 99213 requires at least 1
              Level 99204, 99214 requires at least 2
              Level 99205, 99215 requires at least 10