1. CPT Evaluation and Management Unit 2
HS 225 Medical Coding I
CPT Evaluation and Management
Unit 2

2. E/M Overview
Reflects amount of work involved in providing health care to a patient
Between three and five levels of service 2

3. E/M Section Codes 99201–99499 First section in CPT
Review guidelines at beginning section
Apply applicable notes 3

4. Levels of Service Organized according to: Place of service
Physical location where health care is provided to patients (e.g., office, hospital, home, nursing facility)
Type of service
Type of health care services provided to patients (e.g., new or initial encounter, follow-up or subsequent encounter) 4

5. Example
Dr. Miller completed Jennifer Sullivan’s history and physical on the first day of her inpatient admission
Place of service: hospital
Type of service: initial care
E/M category: hospital inpatient services
E/M subcategory: initial hospital care 5

6. E/M Section Guidelines
Located at beginning of section
Includes:
Classification of E/M services
Definitions of commonly used terms
Unlisted service
Special report
Clinical examples
Instructions for selecting level of E/M service 6

7. Classification of E/M
Categories (e.g., office, outpatient visits, consultations)
Subcategories (e.g., new and established patients)
Five-digit numerical codes (99201–99499)
(continued) 7

8. Classification of E/M Code descriptions include:
Place and/or type of service
Content of service
Detailed history and examination
Nature of presenting problem
Time required to provide service 8

9. Levels of E/M Service History Examination Medical decision making
Counseling
Coordination of care
Nature of presenting problem
Time 9

10. Key Components Three components: New patients Established patients
Extent of history
Extent of examination
Complexity of medical decision making
New patients
Three components required
Established patients
Two of three components required 10

11. Extent of History Four types: Problem-focused Expanded problem-focused
Detailed
Comprehensive 11

12. Extent of History Includes: History of present illness (HPI)
Review of systems (ROS)
Past/Family/Social history (PFSH) 12

13. Extent of Examination Four types: Problem-focused
Expanded problem-focused
Detailed
Comprehensive 13

14. Extent of Examination Multisystem Exam Single Organ Exam
Constitutional
Eye
Ear, Nose and Throat
Neck
Respiratory
Cardiovascular
Chest (Breast)
Gastrointestinal (Abdomen)
Genitourinary
Lymphatic
Musculoskeletal
Skin
Neurologic
Psychiatric
Cardiovascular
Ear, Nose and Throat
Eye
Genitourinary
Hematologic/Lymphatic/Immunologic
Musculoskeletal
Neurological
Psychiatric
Respiratory
Skin 14

15. Medical Decision Making
Four types of complexity:
Straightforward
Low
Moderate
High 15

16. Complexity of Medical Decision Making
Measured by:
Number of diagnoses or management options
Amount and/or complexity of data to be reviewed
Risk of complications, and/or morbidity or mortality 16

17. Complexity of Medical Decision Making
Documentation includes:
Ancillary test results (e.g., laboratory)
Known diagnoses
Opinions of other physicians
Planned course of action
Review of previous records 17

18. Contributory Components
Counseling
Coordination of Care)
Nature of presenting problem
Time 18

19. Contributing Components
Counseling
Coordination of Care
Diagnostic results
Prognosis
Risks and benefits of treatment options
Instructions for treatment and/or follow-up
Compliance with treatment options
Risk factor reduction
Patient and family education
Not formally defined in CPT
Represents services that are completed to organize or direct the patient’s care. 19

20. Nature of the Presenting Problem
Five types:
Minimal
Self-limited or minor
Low severity
Moderate severity
High severity 20

21. Time Face-to-face time Unit/Floor time
Amount of time office or outpatient care provider spends with patient and/or family
Unit/Floor time
Amount of time provider spends at patient’s bedside and managing patient’s care on unit/floor 21

22. Billing According to Length of Time
Document:
Total length of time for the encounter
Length of time spent coordinating and/or counseling
Issues discussed
Relevant history, exam, and medical decision making
Controlling factor if more than 50% of time is spent counseling/coordinating care 22

23. Initial Hospital Care 99221-99223
used by the admitting physician to report the first hospital inpatient encounter
only one of these codes should be
reported per day
All three components of EM should be met 23

24. Subsequent Hospital Care 99231-99233
Reflect the physician’s work for subsequent days of service performed in the hospital 24

25. Hospital Discharge Services 99238, 99239
Codes are time based
Include all services provided to a patient on the date of discharge
Includes:
Final examination of patient
Discussion of hospital stay
Instructions for continuing care
Preparation of discharge records, prescriptions, and referral forms 25

26. Hospital Observation Services 99217-99220
Subcategories
Initial observation care
Observation care discharge services
Used only once per day
When a patient is admitted for observation or observation status, the patient has not been admitted
to the hospital as an inpatient but needs to be admitted under “observation status" for assessment.
Observation indicates the patient is in the hospital for a short time (usually less than 24 hours but
sometimes as long as 48 hours) to 26

27. Initial Observation/inpatient Care
Observation or Inpatient Care Services (including admission and discharge)
Used when a patient is admitted and discharged on the same date of service 27

28. Consultations
Services rendered by providers when their opinion or expertise is requested by another provider
Subcategories
Office or other outpatient services
Initial inpatient consultations 28

29. Emergency Department Services 99281-99285
Used for providers who perform services in the emergency department of a hospital based facility, which is open 24 hours a day, 7 days a week 29

30. Critical Care Services 99291, 99292
Physician directly delivers medical care to critically ill or injured patient
Manages life-threatening conditions
Single or multiple vital organ system failure
Does not have to be provided in a critical care unit
Time must be spent caring for one patient at that time 30

31. Pediatric Critical Care Patient Transport 99466-99467
Critically ill pediatric patients transported to facilities, accompanied by a provider
Pediatric being defined here as 24 months of age or less)
Face-to-face care is required and must be documented 31

32. Inpatient Neonatal and Pediatric Critical Care 99468-99480
Neonate—28 days or younger
Pediatric 29 days to 24 months
Review guidelines at the beginning of the section in regards to the critical services the patients are receiving
VLBW-Less than 1500 g
LBS-=1500 g to 2500 g 32

33. Nursing Facility Services 99304-99316
Initial and Subsequent care
Includes:
Nursing facility (NF)
Skilled nursing facility (SNF)
Intermediate care facility (ICF)/Mentally retarded
Long-term care facility (LTCF)
Psychiatric residential treatment facility 33

34. Domiciliary, Rest Home, and Custodial Care Services 99324-99337
Includes:
Boarding homes
The facility assists patients with ADLs but no medical care 34

35. Home Services 99341-99350 Includes:
Private residence
Provider must document why the patient was seen at home
Travel time is not billable
Only face-to-face time should be documented 35

36. Prolonged Services 99354-99360 Time must be documented
Reported in addition to an E/M service at any level
Physician’s services involving patient contact that are considered beyond the usual service in either an inpatient or outpatient setting
Time must be documented 36

37. Case Management Services 99363-99368
Service provided by an attending physician in which the physician not only supervises but also coordinates direct care received by a patient
Category divided into Anticoagulant Management and Medical Team Conferences
(continued) 37

38. Care Plan Oversight Service 99374-99380
Care plan oversight is a service that is billed once a month and includes all care rendered to a patient over a 30-day period
Billed by only one physician in a group practice over the 30 days to reflect services coordinated or rendered by a physician 38

39. Preventive Medicine Services 99381-99429
“Well Visit” or “Physical Exam”
Age driven
No HPI is associated with the visit
Routine check-up
Annual gynecologic examinations
Other examinations whose focus is promoting health

40. Newborn Care
Service provided in a variety of health care settings, hospitals, birthing centers, and homes that include:
History and examination of normal infant
Attendance at delivery and initial stabilization of newborn
Newborn resuscitation

41. Non-Face-to-Face Physician Service 99441-99444
Telephone Service
E/M service provided by a physician using the telephone
E/M service provided by a physician using the internet
(continued)

42. Special Evaluation and Management Services 99450–99499
Basic life and/or disability examination
Insurance
Work related or medical disability evaluation services
Other evaluation and management services
No other EM code available to accurately describe services

43. Questions