Medical Decision-Making Factors Include Quantity of Information, Complexity

Determining Visit-Level Selection

Determining the final visit level for a particular CPT code (e.g. 9922x) depends upon the key components of history (see “A Brief History,” October 2011), exam (see “Exam Guidelines,” November 2011), and medical decision-making.⁴ For some code categories, each of the three key components must meet the documentation guidelines for the corresponding visit level (e.g. initial hospital care, initial observation care, and consultations).

If all three components do not meet the requirements for a particular visit level, then code selection is determined by the lowest component. For example, the physician must select 99221 when only documenting a detailed history despite having also documented a comprehensive exam and high-complexity decision-making. In other code categories, only two key components must meet the documentation guidelines (e.g. subsequent hospital care and subsequent observation care) for code selection.

Code selection is determined by the second-lowest component. For example, the physician may select 99233 when only documenting an EPF history after having also documented a detailed exam and high-complexity decision-making. Despite this “two component” technicality with subsequent services (99231-99233 and 99224-99226), MDM should be one of the two key components considered during subsequent visit level selection, as it most clearly correlates to the medical necessity of the encounter.