MEDICAL DECISION MAKING – Determine this level first, then ...



MEDICAL DECISION MAKING – Determine this level first, then verify that chart

documentation (HPI, ROS, PFSH & Examination) supports the level. Bold areas are

what are commonly managed in SBHCs.

Use the following chart. If 2 or 3 are in the same level, choose that level. If only 1 is selected in each level, choose the middle level.

|New |99201* |99202 |99203 |99204 |99205[1] |

|Established |99211 |99212 |99213 |99214 |99215 |

|Diagnoses or Management| |-One Self-limited or |-Two or more self-limited |-One or more chronic illnesses |-One or more chronic illness |

|Problems | |minor problem |or minor problems |with complications |with severe complications |

| | | |-One stable chronic |-Two or more stable chronic |-Acute or chronic illness or |

| | | |condition |illnesses |injury that is life or limb |

| | | |-Acute uncomplicated |-Undiagnosed new prob. w/ |threatening |

| | | |illness (e.g., allergic |uncertain prognosis |-Abrupt change in neurologic |

| | | |rhinitis, simple sprain |-Acute illness with systemic |status |

| | | | |symptoms | |

| | | | |-Acute complicated injury | |

|Diagnostic Procedures | |-Lab |-Physiologic tests not |-Physiologic tests under stress|-Cardiovascular imaging with |

|(only 2 areas must | |-X-ray |under stress |- cardiac stress test |contrast |

|agree to determine | |-EKG |-Pulmonary Function |-Diagnostic endoscopies with no|Invasive diagnostic tests |

|medical decision making| |-UA |-Barium enema |risk factors |-Cardiac electrophysiological|

|level, so this area is | |-Ultrasound |-Arterial puncture |-Deep needle or incisional |tests |

|not usually the deal | |-Venipuncture |-Skin biopsies |biopsy |-Diagnostic endoscopies w/ |

|breaker as most SBHC | |-KOH. | |-Obtained fluid from body |identified risk factors |

|do not typically do | | | |-Cardiovascular imaging w/ |-Discography |

|level 3, 4 or 5 | | | |contrast | |

|Diagnostics) | | | | | |

|Treatment of Management| |-Rest |-OTCs |-Minor surgery with risk |-Elective surgery with |

|Options | |-Gargles |-Minor surgery w/ no |factors |identified risk factors |

| | |-Elastic bandages |identified risk factors |-Elective major surgery - no |-Emergency major surgery |

| | |-Dressings |-PT |risk factors |-Parenteral controlled |

| | | |-OT |-Prescription drug management |substances |

| | | |-IVs without additives |-IV fluids with additives |-Drug treatment w/ intense |

| | | | |-Closed fracture or dislocation|monitoring |

| | | | |treatment w/o manipulation |-Decisions not to resuscitate|

| | | | |-Therapeutic nuclear medicine |or de-escalate d/t poor |

| | | | | |prognosis |

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* For a new patient 99201, use the requirements for a new patient 99202

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