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E/M Levels...Help!!

  1. #1
    Default E/M Levels...Help!!
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    I am very confused with how the levels come together if they sometimes do not line up exactly to meet a given level. How are these coded for New vs Established?

    Also, when determining components of history, is it the best 2 of 3 (HPI, ROS,PFSH) for new and established for the overall level??

    Thanks in advance for help!!

  2. Default
    There is alot of great E&M information available on It sounds like you have quite a few questions about how to choose a level of service and on this website there is a Free section that have Audit sheets to help you correctly choose the level of service on a visit.


  3. Default Determining E/M Level
    I'm confused and hope someone can help me understand.

    Clinical documentation for a new in office patient supports comprehensive history, detailed exam, and moderate complexity medical decision making. Am I right in billing 99203 or should it be 99204? Guidelines say for new patients 3 of 3 components are required for a level of service. I don't have 3 of 3. So do I go with the lowest of the three?

  4. Default
    99203 - you have to meet or exceed all three components.

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