PHYSICIAN CODING



INPATIENT INITIAL VISIT, SHORT GUIDE

Summary of Elements Needed for E&M Codes
All notes must have a diagnosis

Note PFSH=PMH, FH, SH

Initial Inpatient - 99221 (30 minutes)
Hx: Detailed (CC, 4 HPI, 2-9 ROS, 1 PFSH)
PE: Detailed (5-7 body areas/systems)
MDM: Straightforward/Low Complexity
Initial Inpatient - 99222 (50 minutes)
Hx: Comp (CC, 4 HPI, 10-14 ROS, 1ea PFSH)
PE: Comprehensive; (8+ body areas/systems)
MDM: Moderate Complexity
Initial Inpatient - 99223 (70 minutes)
Hx: Comp; (CC, 4 HPI, 10-14 ROS, 1ea PFSH)
PE: Comprehensive; (8+ body areas/systems)
MDM: High Complexity

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INPATIENT FOLLOW-UP VISIT, SHORT GUIDE

Summary of Elements Needed for E&M Codes
All notes must have a diagnosis

Note PFSH=PMH, FH, SH

Subsequent Inpatient - 99231 (15 minutes)
Hx: Prob Focused; (CC, 1-3 HPI, 0 ROS, 0 PFSH)
PE: Problem Focused (affected body system)
MDM: Straightforward
Subsequent Inpatient - 99232 (25 minutes)
Hx: Expanded Prob Focused; (CC, 1-3 HPI, problem pertinent ROS, 0 PFSH)
PE: Expanded Problem Focused (2-4 areas)
MDM: Moderate Complexity
Subsequent Inpatient - 99233 (35 minutes)
Hx: Detailed (4 or > HPI, 2-9 ROS, interval PFSH)
PE: Detailed (5-7 body systems)
MDM: High Complexity

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Summary of Elements Needed for E&M Codes
All notes must have a diagnosis

Note PFSH=PMH, FH, SH

Inpatient Consult-99251 (20 min)
Hx: Prob Focused; (CC, 1-3 HPI, 0 ROS, 0 PFSH)
PE: Problem Focused (affected body system)
MDM: Straightforward
Inpatient Consult-99252 (40 min)
Hx: Expanded Prob Focused; (CC, 1-3 HPI, prob pertinent ROS, 0 PFSH)
PE: Expanded Problem Focused (2-4 areas)
MDM: Straightforward
Inpatient Consult-99253 (55 minutes)
Hx: Detailed (4 or > HPI, 2-9 ROS, 1 PFSH)
PE: Detailed (5-7 body systems)
MDM: Low Complexity
Inpatient Consult-99254 (80 minutes)
Hx: Comp; (CC, 4 HPI, 10-14 ROS, 1ea PFSH)
PE: Comprehensive; (8+ body areas/systems)
MDM: Moderate Complexity
Inpatient Consult-99255 (110 minutes)
Hx: Comp; (CC, 4 HPI, 10-14 ROS, 1ea PFSH)
PE: Comprehensive; 8+ body areas/systems
MDM: High Complexity

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INPATIENT DISCHARGE, SHORT GUIDE

99238 (30 minutes or less)
99239 (greater than 30 minutes)
- note should reflect or document the additional time.
Diagnosis must be in note or discharge summary

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OUTPATIENT INITIAL VISIT, SHORT GUIDE

Summary of Elements Needed for E&M Codes
All notes must have a diagnosis

Note PFSH=PMH, FH, SH

Outpatient Initial-99201 (10 minutes)
Hx: Prob Focused; (CC, 1-3 HPI, 0 ROS, 0 PFSH)
PE: Problem Focused (affected body system)
MDM: Straightforward
Outpatient Initial-99202 (15 minutes)
Hx: Expanded Prob Focused; (CC, 1-3 HPI, prob pertinent ROS, 0 PFSH)
PE: Expanded Problem Focused (2-4 areas)
MDM: Straightforward
Outpatient Initial-99203 (25 minutes)
Hx: Detailed (4 or > HPI, 2-9 ROS, 1 PFSH)
PE: Detailed (5-7 body systems)
MDM: Low Complexity
Outpatient Initial-99204 (45 minutes)
Hx: Comp; (CC, 4 HPI, 10-14 ROS, 1ea PFSH)
PE: Comprehensive; 8+ body areas/ systems
MDM: Moderate Complexity
Outpatient Initial-99205 (60 minutes)
Hx: Comp; (CC, 4 HPI, 10-14 ROS, 1ea PFSH)
PE: Comprehensive; 8+ body areas/ systems
MDM: High Complexity

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OUTPATIENT FOLLOW-UP, SHORT GUIDE

Summary of Elements Needed for E&M Codes
All notes must have a diagnosis

Note PFSH=PMH, FH, SH

Outpatient Followup-99212 (10 minutes)
Hx: Prob Focused; (CC, 1-3 HPI, 0 ROS, 0 PFSH)
PE: Problem Focused (affected body system)
MDM: Straightforward
Outpatient Followup-99213 (15 minutes)
Hx: Expanded Prob Focused; (CC, 1-3 HPI, prob pertinent ROS, 0 PFSH)
PE: Expanded Problem Focused (2-4 areas)
MDM: Low Complexity
Outpatient Followup-99214 (25 minutes)
Hx: Detailed (4 or > HPI, 2-9 ROS, 1 PFSH)
PE: Detailed (5-7 body systems)
MDM: Moderate Complexity
Outpatient Followup-99215 (40 minutes)
Hx: Comp; (CC, 4 HPI, 10-14 ROS, 2 PFSH)
PE: Comprehensive; 8+ body areas/ systems
MDM: High Complexity

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OUTPATIENT CONSULT, SHORT GUIDE

Summary of Elements Needed for E&M Codes
All notes must have a diagnosis

Note PFSH=PMH, FH, SH

Outpatient Consult-99241 (15 minutes)
Hx: Prob Focused; (CC, 1-3 HPI, 0 ROS, 0 PFSH)
PE: Problem Focused (affected body system)
MDM: Straightforward
Outpatient Consult-99242 (20 minutes)
Hx: Expanded Prob Focused; (CC, 1-3 HPI, prob pertinent ROS, 0 PFSH)
PE: Expanded Problem Focused (2-4 areas)
MDM: Straightforward
Outpatient Consult-99243 (40 minutes)
Hx: Detailed (4 or > HPI, 2-9 ROS, 1 PFSH)
PE: Detailed (5-7 body systems)
MDM: Low Complexity
Outpatient Consult-99244 (60 minutes)
Hx: Comp; (CC, 4 HPI, 10-14 ROS, 1ea PFSH)
PE: Comprehensive; 8+ body areas/ systems
MDM: Moderate Complexity
Outpatient Consult-99245 (80 minutes)
Hx: Comp; (CC, 4 HPI, 10-14 ROS, 1ea PFSH)
PE: Comprehensive; 8+ body areas/ systems
MDM: High Complexity

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When using extended services codes (99356-357), elements of a usual note do not need to be present, but generally medical decision making should agree with the code chosen. An admission note with extended service should have all the elements. In addition, you may use regular follow-up codes and document by time. Use time-based codes only if >50% of time is spent on coordination/counseling. Time should be denoted as total time and time spent on coordination/counseling. You must also document the extent of c/c (what you talked about/coordinated, etc.) If the entire time was spent on counseling, one time element need only be documented, but you must document that the entire time was spent on counseling. The following constitutes coordination and counseling:

Coordination of care:
-Scheduling of other services
-Helping patients make treatment and care decisions
-Coordination of care with other providers and agencies

Counseling: (NOTE: According to Medicare, M.A., and most payers, the presence of the patient is required during counseling time; the family may or may not be present.
Conveying diagnostic results and impressions
Outlining patient's prognosis
Outlining the risks and benefits of treatment
Addressing compliance issues
Providing patient and family instruction/education
Outlining follow-up instruction

C/C time does not include reviewing the chart, obtaining history, communication barriers.

Critical care codes are used for time managing a critically ill patient at the bedside. They are not reported along with admission or followup E/M codes. They should be reserved for unstable, critically ill patients requiring your presence at the bedside or on the unit. Family conferences held in conjuction with critical care are counted in the total critical care time. Procedures done in conjuction with cc time should not be billed separately unless they are performed at a different time, unrelated to the critical care time spent.

TIME-BASED CODING (Minutes)

Critical Care
99291 (30 - 74)
99291 + 292 (75 - 104)
99291 + 292 + 292 (105 - 134)
99291 + 292 + 292 + 292 (135 - 164)

Initial Inpatient
99222 + 356 (80 - 124)
99222 + 356 + 357 (125 - 145)
99222 + 356 + 357 + 357 (155 - 184)
99223 + 356 (100 - 144)
99223 + 356 + 357 (145 - 174)
99223 + 356 + 357 + 357 (175 - 204)

Subsequent Inpatient
99232 + 356 (55 - 99)
99232 + 356 + 357 (100 - 129)
99232 + 356 + 357 + 357 (130 - 159)
99233 + 356 (65 - 109)
99233 + 356 + 357 (110 - 139)
99233 + 356 + 357 + 357 (140 - 169)

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