CPT® E/M CODE REQUIREMENTS CPT® E/M CODE REQUIREMENTS

The Physician Documentation Improvement

Level of Service (LOS) is ultimately dependent on medical-decision-making (MDM). Generally, the Physicians must document patient’s complaint and 2 of 3 MDM sections. An established patient
single highest point score on the Table of Risk will be the LOS limiting factor.
Pocket Guide, SECOND EDITION
= same billing group + same physician or same specialty/subspecialty within 3 yrs. Established
MDM3 - Table of Risk - Use single highest point patients need 2 of 3 ( History [Hx] / exam / MDM ). No physician service is needed for 99211.
Points Risk of illness / injury Risk of testing Risk of treatment
Pamela P. Bensen, MD, MS, FACEP
New Office 99201 99202 99203 99204 99205 For Pocket Guide Instructions, visit: www.hcpro.com/downloads/10530
4 Chronic + severe exacerbation/ CVS imaging + risk Elective major surgery + risk
treatment side effect Cardiac electrophysiologic test Emergency major surgery
Established 99212 99213 99214 99215* This guide should accompany documentation education to acquaint
ED 99281 99282 99283 99284 99285*
Life / function threatening Diagnostic endoscopy + risk Parenteral controlled Rx the user with basic clinical documentation concepts to support medical necessity,
OP 99241 99242 99243 99244 99245

Not CMS
- Mult trauma, MI, PE, Discography Rx therapy + toxicity monitor severity of illness (SOI), quality reporting, and correct ICD-9-CM coding.
99251 99252 99253 99254 99255

Consult
IP
acute resp failure Poor prognosis - De-escalate
- psych + threat to self / others care CMS OP Use office codes above, new or established patient Documentation Tips
- peritonitis, acute renal failure DNR decision CMS IP 99499 99499 <Unlisted code submit notes 99221 99222 99223 History & Physical (H&P) - Reason for Admission/Surgery
Neuro change, AMS, seizure, Initial Observation 99218 99219 99220 Indicate acuity, even when it is obvious: congenital, chronic, acute, acute on chronic, acute exacerbation.
TIA, weakness, sens loss Initial Observation, discharge same date 99234 99235 99236 Detail pathology requiring admission or surgery. List every diseases/conditions POA that is ‘suspected,’
Initial Hospital 99221 99222 99223 tested for, treated, monitored, or medicated (prior to & after admission) & link with underlying causes.
3 Chronic + mild exac/tx side Stress tests Rx management Document significance & interdependence of coexisting conditions requiring equal attention.
effect Diagnostic endoscopy, no risk IV fluids + additives Subsequent
Observation 99224 99225 99226 Present on Admission (POA) = Hospital Acquired Condition (HAC), if not in H&P
2 stable chronic illnesses Deep needle / incision biopsy Minor surgery + risk factors
Undiagnosed new problem - CVS imaging, no risk factors Elective major surg, no risk Hospital 99231 99232 99233 Foreign object retained after surgery Air embolism Surgical site infection post:
breast lump Get body cavity fluid - LP, Therapeutic nuclear med HPI 1 1 1 1 4 4 4 4 4 4 DVT & PE post orthopedic procedures Blood incompatibility • CABG - Mediastinitis
Manifestations of poor glycemic control Cath associated UTI • Orthopedic procedures
Acute, systemic sx - colitis, thoracentesis Closed fx/dislocation no ROS 1 1 1 2 2 2 2 10/caveat**
Vascular cath infection/clot/etc Stage 3/4 pressure ulcers • Obesity bariatric surgery
pneumonitis, pyelonephritis manipulation PFSH 1 1 1 1 2*/3 2*/3 Pneumothorax with venous cath
Complicated injury - head injury • CIED Procedures
Exam or 1 2 2 2 6 6 6 6 8 8 Falls/trauma, fx, dislocations, intracranial injuries, crush injuries, burns, electrical shock
brief LOC
1 system Before signing orders, think: Does the patient have a pressure ulcer (where)?
2 2 self-limited / minor Non-cardiac contrast test, BE OTC medications What is causing the anemia, WBC, pneumonia? Is there R heart failure with the Cor pulmonale?
limited extended complete
1 Stable chronic - HTN, DM, BPH Superficial needle biopsies IV fluids no additives Is pulmonary edema cardiogenic or non-cardiogenic? Is cardiac dysfunction heart failure or not?
Acute, uncomplicated - Arterial puncture labs PT / OT MDM1 1 1 2 3 1 2 3 4 3 4
Is there acute/chronic osteomyelitis?...?...? Remember SOI counts!
cystitis, rhinitis, sprain Skin biopsies Minor surgery, no risk MDM2 2 3 2 3 4 3 4
Progress & Daily Post-Op Notes
1 1 Self-limited / minor - cold, Lab, x-ray, EKG, or US Rest, gargle MDM3 1 1 2 3 1 2 3 4 3 4
Document a disease for every positive test/finding & indicate its significance.
insect bite, tinea Non-stress tests, PFTs Bandage, ace Show logical progression of conditions, resolution looks good. If no improvement, note additional conditions, alternative care
HPI 4 points - document Pt condition prevents Hx PFSH *only 2 for codes Counseling
Day of Discharge 99217 Observation discharge DOS is not the same as admission DOS considered, level of service discussions, and end-of-stay / life planning.
Hospital discgarge, total time for all DOS services 99238 < 30 min 99239 > 30 min Location Duration Modifying factors Past 99285 & 99215 Time - min
Quality Timing Associated signs & symptoms Family Subsequent hospital 99201 10 Document: New conditions as unexpected or expected and inherent-to or complication-of procedure/tx
Time dependent codes - Total time for date of service (DOS) Severity Context Assoc comorbid conditions Social = interval hx 99202 20 • post-op confusion/acute delirium probable toxic (anesthetic/narcotic) encephalopathy
Time is for counseling, critical care, telephone, and prolonged service only. 99203 30 • atrial fibrillation integral to CABG
Critical Care ROS Exam MDM1 - sum of points 99204 45 • vomiting & abd distention is from unexpected ileus from narcotics (or expected w bowel surgery)
Prolonged Care Post-op conditions, like ileus, fever, atelectasis, anemia, may be coded as complications unless physician documents
NOT an ICU code, use anywhere. Physician cannot leave 99205 60
Face-to-face NOT face-to-face 10**Pertinent +/- Const- VS/appearance Presenting problem SOI ‘expected consequence’ of condition/surgery/Rx.
patient bedside. Document time & critical conditions 99212 5
"all other systems Eyes 1 1 Self limited / minor illness / injury Document: if ‘acute blood loss anemia’ is disease related (from GI bleed or hip/pelvic fx)
99291 30-74 min 99354 OP 30-74 99358 30-74 99213 15
negative" ENT, Mouth 2 2 Self limited / minor illness / injury if red/indurated wound is expected wound infection from peritonitis present at surgery
99292 additional 30 min after 74 99355 OP +30 99359 +30 99214 25
99356 IP 30-74
Constitutional CVS 2 1 Established / worse illness / injury
99215 40 Signs/symptoms? Document ‘suspected’ disease! Uncertainty is OK for inpatients!
Eyes Respiratory 4 2 Established / worse illness / injury Chest pain Probable accelerated angina, pleurisy, GERD, costochondritis…
99357 IP +30 99221 30
Included services: chest x-rays (71010, 71015, ENT, Mouth GI or abdomen 3 New illness / injury no workup AMS, altered Encephalopathy suspected due to…anoxia, metabolic disorder, sepsis, toxin, trauma
99222 50 Syncope Suspect arrhythmia/orthostatic hypotension/TIA/autonomic neuropathy…
71020), interpretation of cardiac output (93561-62), Established patients only CVS GU/Genital+groin+butt 4 New illness / injury workup needed
99223 70 Sick patient? Hypotension? Document ‘shock’ cardiogenic/septic/hypovolemic.
pulse oximetry (94760-62), blood gases, data stored Unrelated to an E/M within 7 days Respiratory MS
MDM2 - sum of points 99231 15 Consider SIRS, document if non-infectious (from trauma, burns, pancreatitis) or from infection.
in computers (ECGs, BPs, hematologic data 99090); Day of Discharge* e-mail GI Skin
Document summery of following in notes 99232 25 If sepsis, document if it is due to a condition requiring surgery.
gastric intubation (43752, 91105); temporary 99441 5-10 min 99444 GU Neurological Multi-organ failure conveys less SOI than a list of failed organs plus severity & acuity of conditions: ‘acute respiratory failure’
99233 35
transcutaneous pacing (92953); ventilator 99442 11-20 min MS Psychiatric 1 Lab Document request for & ‘acute renal failure’ with ‘severe acute blood loss anemia’
management (94002-94004, 94656, 94660); vascular 99443 99241 15
21-30 min Skin / breast Hem/lymph/immune 1 ECG 1 Old record Discharge Summary
access (36000, 36410, 36415, 36540, 36591, 36600) *Telephone services 99242 30
Neurological Head & face 1 Rad 1 Non-patient historian Single most important part of record
99243 40
Services not included in Critical Care Psychiatric Neck
99244 60 Short story of the patient's illness onset through discharge plus plans for future care
2 Image read by me & documented Summation of all conditions, diseases, findings, treatments, and course of events
92950 Management of CPR Endocrine Chest + breast + axilla
2 Old record reviewed & summarized 99245 80
Hem / lymph Back + spine Convincing closing argument for patient's maximum SOI during admission.
76937 Ultrasound vascular access needs image & procedure note in record 2 Identify non-patient historian 99251 20
Allergic / Immun Extremity Surgical Considerations
Don’t forget to document these important conditions 2 Documented discussion with consultant 99252 40
99253 55 Complications: Indicate if surgical procedure is needed to treat a previous surgical complication, failure of care, or late
• Acute esophageal/gas- • (Chronic) DVT • Hypoaldosteronism/ • Peritonitis effect of medical treatment.
99254 80
tric/duodenal/peptic/­ • Continuous chemical adrenalism/pituitarism • Radiation/toxic Surgery + serious coexisting medical conditions: Acute blood loss anemia, atelectasis, ileus, AMI, shock, SIRS, sepsis,
gastrojejunal ulcer 99255 110
dependency • Ileus/gastroparesis gastroenteritis/colitis coma, acute respiratory/renal failure, and stroke increase SOI.
• Acute paranoid • Crohn’s • Intestinal impaction • Rectal abscess Malnutrition is the most important predictor of surgical morbidity & mortality (SOI).
reaction • Diverticulitis • Mechanical/infectious • Specified Document diseases, not signs / symptoms, & link them to underlying If cachectic, morbidly obese get a dietary consult, and document results with specific BMI.
• All arrhythmias G-tube complication schizophrenia
• DKA, HHS causes. If in doubt, document ‘suspect,’ ‘possible,’ ‘likely,’ ‘probable’ Trauma: Pathological fractures are due to osteoporosis/penia/myelitis or tumor.
• Atrial (fib)/flutter • Nephrosis • Sprue
• Drug withdrawal disease. Document a disease for each abnormal test. Document loss of consciousness & duration. Multiple trauma: list all injuries (ruptured spleen, rib & pelvic fractures);
• Bi/tri-fascicular block • Encephalopathies • Obstructed hernia • Ulcer with perforation ‘possible’ organ (lung) contusions; respiratory failure in order of decreasing severity
• Bile duct obstruction • Esophageal varices • Pericardial tamponade • Ulcerative colitis Op notes: Codes come from procedure narratives; document all procedures, intra-op tests, pathology found, extraordinary
• Bipolar disorder • Gangrenous hernia • Pericarditis • Ureteral stone circumstances, unexpected findings, tissue removed, abscesses drained, implanted devices (stents/prostheses). Record if
• Bowel hemorrhage • Hemiparesis • Peripheral autonomic • V tach intraoperative lacerations/bleeding are ‘inherent-to’ or ‘complication-of’ the underlying condition or the procedure.
• Bowel obstruction neuropathy Contact your customer service representative about bulk orders and purchases of additional packs of this pocket guide.
• Hydrocephalus Document everything that increases op time & if lysed adhesions were ‘usual’ or ‘excessive.’
Call toll-free 800-650-6787 or email customerservice@hcpro.com. ISBN: 978-1-60146-948-9 PDPG252
Clinical indicators Encephalopathy Global brain dysfunction 2º anoxia, HTN, metabolic Severity of Illness ICD-9-CM Terms
When uncertain of diagnosis, use possible..., probable..., suspected..., likely… (acid/alkalosis/uremia), sepsis, toxin (drug/EtOH), trauma
Patient severity of illness (SOI) is conveyed to quality organizations and payers
If uncertain at discharge, document uncertainty in last note & discharge summary Heart failure Not CHF! Document: acute, chronic, or acute on chronic and systolic, diastolic, or both through ICD-9-CM codes assigned by a coder who reads the medical record.
Acidosis Labs might include pH < 7.35, pCO2 > 45, HCO3 < 18, anion gap >12 Chronic Acute findings similar in all 3 types Coding rules dictate what codes are assigned to which medical terms.
Document as uncompensated or compensated & respiratory, metabolic, or mixed Systolic HF EF < 40% Cx-ray Cardiomegaly PND, NVD BNP
Heart can’t contract 2º car- S3 gallop Rales < 100 - No HF Nonspecific SOI  SOI
 
Primary Compensatory response ACS, angina Accelerated/decubitus angina MI
Metabolic acidosis diomyopathies, pulmonary ECHO Dilated Acute Pul edema < 300 - Suggests HF
 pH ≅  HCO3  pH ≅  HCO3   BNP > 400 - Mild Altered mental status Dementia with acute confusional state Coma
HTN, myocarditis
PaCO2  PaCO2 Altered (Senile) dementia + behavioral changes Brain death
Diastolic HF EF - normal EKG LVH CVP > 16cm > 600 - Moderate
Respiratory acidosis  pH ≅ HCO3  pH ≅   HCO3 (Pre)senile/vascular dementia w delirium/
Heart can’t relax, 2º CAD, S4 gallop HJR, Pul edema > 900 - Severe
  PaCO2  PaCO2 delusion/depression
severe aortic stenosis, ECHO abnl relaxation Visceral congestion
AMS Acute delirium/dementia Encephalopathy
Acute blood loss anemia 20%  HCT hypertrophic/ restrictive Cardiomegaly at autopsy
Likely to be HTN Anemia Acute/chronic blood loss anemia;
Acute exacerbation Awaken at night w/ symptoms,  exercise tolerance,  therapy/inhalers cardiomyopathy   Wt > 4.5kg in 5 days requiring CHF Tx precipitous drop in HCT
COPD/asthma   Frequency/duration of cough, wheezing, SOB Both - Any EF Combination Specific types of anemia Specified aplastic anemia
Yellow sputum, antibiotics, hemoptysis Hypercoagulable syndrome Virchow’s triad Anemia 2º chemo Aplastic anemia; pancytopenia Drug induced pancytopenia
Change in oxygen status, BiPAP/ pO2 need Hypercoagulability 1° - Factor V Leiden, Protein C/Protein S deficiency Cachexic (Mild/moderate) malnutrition; Severe malnutrition
pO2 > 10 mm Hg from base (see respiratory failure) 2° - Estrogen, cancer, pregnancy Cachexia with BMI< 19
Acute renal failure SCr 0.3 mg/dl in 48 hrs KDIGO criteria Stasis Debility, illness, surgery, travel CVS Cardiomyopathy Cardiogenic shock
CHF/fluid overload Chronic systolic/diastolic HF Acute systolic/diastolic HF
Acute Kidney Injury SCr 1.5 x base in 7 days Thrombophlebitis DVT, phlegmasia cerulea dolens (severe DVT), PE
Cholecystitis Chronic cholecystitis Acute cholecystitis
Urine output <0.5 ml/kg/h for 6 hrs HTN COPD/asthma Acute exacerbation COPD/asthma Acute respiratory failure
Acute respiratory failure Patient in respiratory distress & needs close monitoring, but ICU & vent not Pre-hypertension 120–139 or 80–89 Cystitis Urosepsis/UTI Sepsis due to UTI
necessary, recovery is possible Benign/essential 140–159 or 90–99 End stage COPD on Chronic respiratory failure Acute respiratory failure
pH ≤ 7.35 & pCO2 ≥ 50 or pO2 < 55 (sat < 88%) & FiO2 > 28% Accelerated HTN 160–179 or 100–109 + vague symptoms (headache or dizziness) home O2
Alkalosis Labs might include pH > 7.45, pCO2 < 28, HCO3 > 28, anion gap < 12 Malignant HTN >180 or >120 + organ failure Esophagitis Acute esophagitis
Document as uncompensated or compensated and respiratory, metabolic, or mixed Malnutrition Morbid obesity with specific BMI value if > 40 Fever Non-infectious SIRS Non-infectious SIRS +
Primary Compensatory response Cachexia with BMI < 19 Confirm w/ dietary consult organ failure
Metabolic alkalosis Myelodysplasia  RBC,  WBC,  platelet with dysplastic bone marrow Fracture of… Pathological fx 2º osteoporosis/penia/tumor
  pH ≅   HCO3   pH ≅    HCO3 GI GI bleed/ulcer/hematemesis Specified site of bleed
PaCO2   PaCO2 Myocardial infarction Troponin >99th percentile + sx/sy
Hepatitis Specified chronic hepatitis Specified acute hepatitis
Respiratory alkalosis Pancytopenia  RBC,  WBC, and  platelets
  pH ≅ HCO3   pH ≅   HCO3 Hepatic encephalopathy
Pathological fracture Osteoporosis/penia, tumor, atraumatic (minimal trauma) HIV Positive AIDS
 PaCO2  PaCO2 Pneumonia Document if ‘sepsis’, ‘acute respiratory failure’, ‘acute interstitial pneumonitis’ is Hypertensive urgency Accelerated HTN
Chronic kidney disease Stage 1 2 3 4 5 present. Justify antibiotics & treatments, document ‘suspected’ underlying organism HTN emergency, crisis Malignant HTN requires a documented organ failure
CKD + stage GFR > 90 60–89 30–59 15–29 < 15 (use facility antibiogram)/cause.
Infection Bacteremia; thrush Septicemia/sepsis
Presumptive organism Presumptive Rx Gram (-) Aspiration
Chronic respiratory failure Usually on home O2 for chronic hypoxemia Specified/suspected infections
Anaerobes Clindamycin/ Bacteroides Anaerobes
(Partially) compensated respiratory acidosis Influenza Influenza d/t avian/H1N1 virus
Imipenem+Flagyl
pO2 < 55 (O2sat < 88%) or pCO2 > 50 with pneumonia
Gram (-) rods, anaerobes Zosyn/Unasyn Prevotella Anaerobic strep
Continuous/daily use Addiction/obsession to use despite severe consequences. Kidney disease CKD 4-5, acute renal failure or kidney injury ESRD
MRSA, other gm (+) Zyvox Porphyromonas Bacteroides
chemical dependency Cessation causes withdrawal symptoms. Gram (-) rods Gentamycin/Tobramycin Fusobacterium Prevotella
Obesity Morbid obesity, give specific BMI if > 40;
CVA or Stroke Sx >24 hrs or CT/MRI positive Anaerobes, gm(-) rods Primaxin Chlamydophilia Fusobacterium
obesity hypoventilation syndrome
Cerebral embolism/thrombosis no infarction Sx 1–24 hrs and CT/MRI negative Enterococci, Staph Vancomycin Mycoplasm S. aureus
Pancreatitis Chronic pancreatitis Acute pancreatitis
TIA Sx < 1 hr and CT/MRI negative Aureus Pleural effusion Pleural effusion due to X
Pseudomonas Fortaz/Maxipime Klebsiella Legionella (Post-Op) anemia Acute blood loss anemia
Debridement Mycoplasma, Legionella Erythromycin/Doxycycline Legionella Gram (+)
Excisional debridement- surgical removal or cutting away of devitalized tissue or slough. Precipitous drop in HCT
Fungus Amphotericin/fluconazole Staph Pulmonary embolus Chronic pulmonary embolus Acute pulmonary embolus
May be performed by a nurse, therapist, physician assistant, or physician in OR or at bedside. Acid Fast Bacillus INH, Rifampin, Ethambutol Strep
Coding requires “depth” of tissue removed (skin/fascia/muscle/bone) & instrument description. Seizure Specific seizure, grand mal, focal, post
Aspiration Pneumonia (Clindamycin/ Imipenem) Consider aspiration if… traumatic, etc.
Nonexcisional debridement- non-operative brushing, irrigating, scrubbing, or washing of devitalized
TIA Cerebral embolism/thrombosis no infarction Stroke/CVA
tissue, necrosis or slough, includes snipping of tissue followed by Hubbard tank therapy. Aspiration hx Debilitated Esop strictures Nursing home Seizures
resident Troponemia/leak/bump (non)STEMI
Sharp debridement & maggot therapy are non-excisional debridement. (+)BA swallow Deconditioning ET tube/trach Stroke/TIA
Multiple sclerosis Ulcer Ulcer lower limb/thigh/calf/ankle/heel/midfoot Stage 3/4 pressure ulcer w/ site
Escharotomy- other incision of skin and SQ tissue. Alcoholism Diverticula Feeding tube TE fistula
Cellulitis; skin ulcer; gangrene of ulcer
AMS/dementia Drug overdose Gastrostomy Myasthenia gravis Trauma
Diabetes mellitus FBS > 126/symptoms + RBS > 200/2-hr PPBS > 200 Analgesics Elderly GERD NG tube UGI endoscopy Decreased= Hypo…
Uncontrolled DM FBS > 126, RBS > 200, HgbA1c >7.0 Anesthesia Dysphagia Head trauma Parkinsonism Vomiting Increased= Hypo…
Diabetic complications Coma, neurogenic bladder, gangrene, ulcer, retinopathy, autonomic Bronchoscopy Elderly Immunocompro- PPSIs
neuropathy, nephrosis, CKD (include stage) Critical illness/ICU Esop neoplasm mised Recumbency ICD-10-CM documentation changes
Precipitous drop in HCT 20%  HCT, is NOT a complication Trimesters rather than weeks
Diabetic keto acidosis Mild DKA Moderate Severe HHS SIRS - Systemic Inflammatory Response Syndrome Left, right, bilateral, dominant hand/arm
HHS (Hyperosmolar/ Sick patient plus 2 of …. WBC >12K or< 4K T >100.4° F (101° F) or< 96° F Initial visit, subsequent visit, sequellae
hyperglycemic state) BS > 250 > 250 > 250 > 600 >10% bands P >90 (100) Urosepsis - has no code, so stop using the word
pH 7.25–7.3 7–7.25 <7 > 7.3 R >20 Complication -document condition & link to procedure, expected consequence of X, unexpected consequense of X,
HCO3 15–18 10–15 < 10 > 15 Sepsis SIRS 2º infection, (+)BC (bacteremia) adds validity but not required or expected complication of X D/T Y
UA/S ketones Positive...................................................... Small Severe sepsis Sepsis + organ failure Asthma - mild intermittent, moderate persistent, severe persistent; with acute exacerbation; with status
Septic shock SBP< 90 or down 40 mmHg from base 2º sepsis, resistant >1hr to fluid Gustilo open fracture classification (types I, II and III); routine healing or delayed healing; nonunion or malunion
S Osmolality Variable..................................................... > 320 resuscitation. Possibly: Dopamine used, lactic acidosis, oliguria, AMS, and/or AMI - STEMI or nonSTEMI; anterior or inferior; which arteries?
Anion gap > 10 > 12 > 12 < 12 cardiac/limb ischemia 2º BP/CO Angioplasty- body part, approach, devise (stent) & drug eluting?
Patient Alert ...Drowsy ...Stupor/coma... Ventricular Tachycardia 3 PVCs in succession CVA hemorrhagic or occlusive, thrombus or embolus, artery