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Effective January 1, 2023, this information is no longer up-to-date. The material on this page covers only the 1995 and 1997 E/M guidelines and is no longer accurate. A new set of E/M guidelines was released in 2021, with some minor modifcations added for 2023. These new guidelines are now used to document all encounters in both the outpatient and inpatient settings. For the most recent E/M coding guidance, visit our home page here.



Minimal Risk

This is the lowest level of risk possible.  It is required for benign encounters such as a  level 1 new office patient (99201) or a  level 2 office visit with established patient (99202).

This level of risk requires ONE element in ANY of the following three categories:

Presenting Problem(s)
  • One self-limited or minor problem (e.g., insect bite, cold)
Diagnostic Procedure(s)
  • Lab tests
  • Chest X-ray
  • Urinalysis
  • Ultrasound/Echocardiography
  • KOH prep           
Management Options Selected
    • Rest
    • Gargles
    • Elastic bandages
    • Superficial dressings
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