Diagnoses or problems are categorized by the following:
Minimal complexity = 1 point from below (99202 or 99212)
Low complexity = 2 points from below (99203 or 99213)
Moderate complexity 4 = 3 points from below (99204 or 99204)
High complexity 5 = 4 points from below (99205 or 99215)
Problem points:
Self-limited or minor (insect bite), 1 point.
Established problem, improving or stable (hypertension, stable), 1 point.
Established problem, worsening (asthma, deteriorating), 2 points.
New problem, no additional workup planned (cellulitis), 3 points.
New problem, additional workup planned (chest pain), 4 points.
When treating different problems, you can add points from the above, but you can get no more than 2 points from the self-limited category. Also, you must document if you are going to do additional workup to get the credit. Simply telling your nurse to order a stress test is not sufficient.
Medical Coding and Billing For Residents 