Fun Coffee with CCO #31

[Lori]

Good Morning Coders!
What are you coding today?

99204
99214

Moderate
• 1 or more chronic illnesses
with exacerbation,
progression, or side
effects of treatment;
or
• 2 or more stable chronic
illnesses;
or
• 1 undiagnosed new
problem with uncertain
prognosis;
or
• 1 acute illness with
systemic symptoms;
or
• 1 acute complicated injury

Moderate
(Must meet the requirements of at least 1 out of 3
categories)
Category 1: Tests, documents, or independent
historian(s)
• Any combination of 3 from the following:
• 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
historian(s)
or
Category 2: Independent interpretation of tests
• Independent interpretation of a test performed
by another physician/other qualified health
care professional (not separately reported);
or
Category 3: Discussion of management or test
interpretation
• Discussion of management or test
interpretation with external physician/other
qualified health care professional\appropriate
source (not separately reported)

Moderate risk of morbidity
from additional diagnostic
testing or treatment
Examples only:
• Prescription drug
management
• Decision regarding minor
surgery with identified
patient or procedure risk
factors
• Decision regarding elective
major surgery without
identified patient or
procedure risk factors
• Diagnosis or treatment
significantly limited by
social determinants of
health