Number and Complexity of Problems Addressed

This week we’ll look at how the various authoritative sites describe Number and Complexity of Problems Addressed.

First let’s look at the AMA’s definition in the now familiar document “cpt-office-prolonged-svs-code-changes.pdf”, titled CPT® Evaluation and Management (E/M) Office or Other Outpatient (99202-99215) and Prolonged Services (99354, 99355, 99356, 99XXX) Code and Guideline Changes.

Page 3: Number and Complexity of Problems Addressed at the Encounter says

… Comorbidities/underlying diseases, in and of themselves, are not considered in selecting a level of E/M services unless they are addressed and their presence increases the amount and/or complexity of data to be reviewed and analyzed or the risk of complications and/or morbidity or mortality of patient management. The final diagnosis for a condition does not in itself determine the complexity or risk, as extensive evaluation may be required to reach the conclusion that the signs or symptoms do not represent a highly morbid condition. Multiple problems of a lower severity may, in the aggregate, create higher risk due to interaction. ….

In a prior posting, we provided an E/M documentation tip from WPS GHA. In their introduction of documentation tips for E/M coding, WPS GHA reminds the reader (bold font is theirs) “Evaluation and Management (E/M) Services Documentation must support the level of service billed and the medical necessity for the level billed.“

“Medicare requires a face-to-face encounter with a patient consisting of elements of both evaluation and management

  • The evaluation portion is substantiated when the record includes documentation of a clinically relevant and necessary exchange of information between provider and patient
  • The management portion is substantiated when the record demonstrates an influence on patient care (ex.; medical decision making, patient education, etc.).”

First Coast’s FAQ about Number and complexity of problems addressed at the encounter reiterates the AMA’s definition.

Effective for dates of service on and after January 1, 2021, the “Number of Diagnoses and Management Options” has been changed to “Number and Complexity of Problems Addressed at the Encounter.”

One element in the level of code selection for an office or other outpatient service is the number and complexity of the problems that are addressed at an encounter. Multiple new or established conditions may be addressed at the same time and may affect medical decision making. Symptoms may cluster around a specific diagnosis and each symptom is not necessarily a unique condition. Comorbidities/underlying diseases, in and of themselves, are not considered in selecting a level of E/M services unless they are addressed and their presence increases the amount and/or complexity of data to be reviewed and analyzed or the risk of complications and/or morbidity or mortality of patient management. The final diagnosis for a condition does not in itself determine the complexity or risk, as extensive evaluation may be required to reach the conclusion that the signs or symptoms do not represent a highly morbid condition. Multiple problems of a lower severity may, in the aggregate, create higher risk due to interaction.

Novitas’ EM Score Sheet instructions says:

The number and complexity of problem(s) that are addressed during the encounter

This section allows you to identify the office or other outpatient service level which corresponds to the number and complexity of the problems that are addressed at an encounter. Multiple new or established conditions may be addressed at the same time and may affect medical decision making. Symptoms may cluster around a specific diagnosis and each symptom is not necessarily a unique condition.

You can find Novitas’ FAQ on the 2021 E/M at this link.

Some key thoughts from these descriptions are:

Comorbidities/underlying diseases, in and of themselves, are not considered in selecting a level of E/M services unless they are addressed and their presence increases the amount and/or complexity of data to be reviewed and analyzed or the risk of complications and/or morbidity or mortality of patient management.

Questions to consider:

Does the documentation identify the conditions addressed?

Does it demonstrate the influence on the patient’s care?


The final diagnosis for a condition does not in itself determine the complexity or risk, as extensive evaluation may be required to reach the conclusion that the signs or symptoms do not represent a highly morbid condition.

Questions to consider:

Does the documentation describe the risk of morbidity/mortality for the conditions addressed?


Multiple problems of a lower severity may, in the aggregate, create higher risk due to interaction.

Questions to consider:

Does the documentation describe the risk of morbidity/mortality of the conditions’ comorbidities?

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