Problem focused history (established chief complaint and 1–3 HPI elements)
Problem focused exam (1–5 elements)
Straightforward medical decision making (self-limited or minor problem)
Time spent: 10 min
99202 – Expanded visit
Expanded problem focused history (1–3 HPI elements), no ROS or PFSHx required
Expanded problem focused exam (6–11 elements)
Straightforward medical decision making
Time spent: 20 min
99203 – Detailed visit
Detailed history
Establish chief complaint, ≥ 4 HPI elements in HPI or status of 3 chronic conditions
Extended problem pertinent ROS (includes 2–9 systems)
Patient’s past history, family history, OR social history (1 PFSHx)
Detailed exam (≥ 12 elements)
Low complexity (one new problem) medical decision making
Time spent: 30 min
99204 – Comprehensive visit
Comprehensive history: ≥ 4 HPI elements or status of 3 chronic conditions, complete ROS (≥ 10 systems), one element each from PHx, FHx, and SHX (3 PFSHx)
Comprehensive exam: complete single system specialty or complete multisystem exam
Moderate complexity decision making
Time spent: 45 min
99205 – Comprehensive visit
Comprehensive history/exam, high complexity decision making; time spent: 60 min
