What is a 99201 for E and M coding?

For a physician, nurse practitioner or physician assistant to be compensated for the services they provide to a patient they must correctly document the events that occurred in the room.  While most medical practitioners document the items, they feel are pertinent, however, CMS has specific criteria that must be documented for each level of service.

The E and M code 99201 is the specific code for a new patient Level 1 patient and is used less often than higher codes such as 99203, 99204 and 99205.  The biggest reason for the low use of this level of service is due to the risk the patient presents with is typically much higher than the minimal risk required for a 99201 level of service.  Also, for a new patient visit most practitioners will complete a comprehensive history and exam at a minimum and in my mind, this should be done. After all this patient is new to the practice and a detailed history and exam is warranted regardless of the presenting complaint.

The items needed to code for this Level of service are made up of the 3 components of the progress note.  For a new patient, all 3 components must be met.

1.) History-

  1. History of present illness- Duration, location, severity, modifying factors, associated symptoms, context, quality and timing

  2. Past medical family and social history

  3. Review of Systems – 14 recognized systems

  • Constitutional (e.g., fever, weight loss)

  • Eyes

  • Ears, Nose, Mouth, Throat

  • Cardiovascular

  • Respiratory

  • Gastrointestinal

  • Genitourinary

  • Musculoskeletal

  • Integumentary (skin and/or breast)

  • Neurological

  • Psychiatric

  • Endocrine

  • Hematologic/Lymphatic

  • Allergic/Immunologic 

2.) Exam- The physical exam component is comprised of  

  • Constitutional (e.g., vital signs, general appearance)

  • Eyes

  • Ears, nose, mouth and throat 

  • Cardiovascular 

  • Respiratory 

  • Gastrointestinal 

  • Genitourinary 

  • Musculoskeletal 

  • Skin 

  • Neurologic

  • Psychiatric 

  • Hematologic/lymphatic/immunologic

3.) Medical Decision Making

  1. Diagnosis

  2. Treatment options- Medications, referrals, splints, etc..

  3. Data review – Old records, labs, medical tests, imaging, etc…

  4. Level of Risk – Minimal, low, moderate and high

For a new patient 99201 the following items must be met for each of the three components.

  • History – one element of HPI, zero systems reviewed, and no PMFSH

  • Exam- Minimum of one system

  • MDM -minimal risk complaint and needs to have either one diagnosis, one treatment option or one data review.


27 yo male here for complaint of seasonal allergies and has used OTC Flonase with mild relief.

Exam - ENT – clear nasal discharge noted

Diagnosis – Seasonal allergies

As you can see from the above example it does not take much documentation to bill for a 99201.

The other option for billing for Evaluation and management codes is the unit of time.  For a 99201 the practitioner must spend at least 10 minutes face to face with the patient and half of the time spent counseling the patient on treatment, lab results, and planning.  All of these components should be documented.