E/M Calculator – Connect Coder

E/M Calculator

Encounter Data

Date of Service

Save

PROBLEMS
1 Self-limited or minor problem
2 or more self-limited or minor problems
1 Stable chronic illness
1 Acute, uncomplicated illness or injury
1 Stable, acute illness
1 Acute, uncomplicated illness or injury requiring hospital inpatient or observation level of care
1 or more chronic illnesses with exacerbation, progression, or side effects of treatment
2 or more stable chronic illnesses
1 Undiagnosed new problem with uncertain prognosis
1 Acute illness with systemic symptoms
1 Acute complicated injury
1 or more chronic illnesses with severe exacerbation, progression, or side effects of treatment
1 Acute or chronic illness or injury that poses a threat to life or bodily function

AMOUNT &/OR COMPLEXITY OF DATA TO BE REVIEWED & ANALYZED

Test & Documents (T&D)	Data Level
Review of prior external note(s) from each unique source Review of the result(s) of each unique test Ordering of each unique test
Assessment requiring an independent historians (0 or 1 Max)
Independent interpretation of a test performed by another physician/other qualified health care professional (not separately reported) (0 or 1 Max)
Discussion of management or test interpretation with external physician/other qualified health care professional/appropriate source (not separately reported) (0 or 1 Max)

RISK OF COMPLICATIONS &/OR MORBIDITY OR MORTALITY OF PAIN MANAGEMENT
Minimal risk of morbidity associated with problem, test or treatment Examples: Rest, gargles, elastic bandages, superficial dressings
Low risk of morbidity associated with problem, test or treatment Examples: OTC drugs, minor surgery w/o identified risk factors, PT OT therapy, IV fluids w/o additives Prescription refills w/o documentation of management
Moderate risk of morbidity associated with problem, test or treatment Examples: Prescription drug management (new Rx, refills with management) Decision regarding minor surgery w/identified patient or procedure risk factors Decision regarding elective major surgery w/o identified PT or procedure risk factors Diagnosis or treatment significantly limited by social determinants of health
High risk of morbidity associated with problem, test or treatment Examples: Drug therapy requiring intensive monitoring for toxicity Decision regarding elective major surgery w/identified patient or treatment risk factors Decision regarding emergency major surgery, hospitaliation, or escalation of care Decision not to resuscitate or to de-escalate care because of poor prognosis Parenteral controlled substances

Final Level of Medical Decision Making

Time-Based Coding

TIME-BASED E/M LEVEL

Copyright © 2024 ConnectCoder. All rights Reserved.

CPT is a registered trademark of the American Medical Association.