When documenting a case for billing, the level of service is determined primarily by the complexity of medical decision-making (MDM), which is categorized into three types: straightforward, low complexity, moderate complexity, and high complexity. Key factors influencing MDM levels include the number of diagnoses and management options, the amount and complexity of data reviewed, and the risk of complications or morbidity associated with the patient's condition. Accurate documentation of these elements is essential for justifying the billed level of service.
Straightforward decision making
It's an office or other out-patient consultation involving a comprehensive history and examination, and medical decision making of moderate complexity.
99201
99253
This service code is for a medical consultation that include three components: a comprehensive history, a comprehensive examination, and medical decision making of moderate complexity.
99285 is a CPT code for an: Emergency department visit for the evaluation and management of a patient with a comprehensive history and examination, and medical decision making of high complexity.
Office/outpatient E & M of new patient requiring 3 components: comprehensive history & examination, and medical decision making of moderate complexity
The code you are looking for is 99203.
MDM means medical decision making. In coding terms, it represents the complexity o the choices the clinician has to make among possible treatment and evaluation modalities.
99284 is a CPT procedure code for: Emergency department visit for the evaluation and management of a patient with a detailed history and examination, and a medical decision making of moderate complexity.
Office/outpatient E & M of new patient requiring 3 components: comprehensive history & examination, and medical decision making of moderate complexity