Hospital visit CPT code 99221, 99222, 99223 Requirements

Evaluation & management tips: Initial hospital care, new or established patient

Key points to remember

The key components (elements of service) of evaluation & management (E/M) services are:
1. History,
2. Examination, and
3. Medical decision-making.
When billing initial hospital care, all 3 key components must be fully documented in order to bill. When counseling and/or coordination of care dominates (more than 50%) the physician/patient and/or family encounter (at the bedside and floor/unit time in the hospital), then time may be considered the key or controlling factor to qualify for a particular level of E/M services. The extent of such time must be documented in the medical record.
CPT codes and requirements

99221 - 30 minutes (average)

• Detailed OR comprehensive history. Documentation needed:
• Chief complaint
• Extended history of present illness
• Detailed - Extended review of systems; Pertinent past, family and or social history
• Comprehensive - Complete review of systems; Complete past, family, and social history
• Detailed OR comprehensive examination. Documentation needed:
• Detailed - Extended examination of the affected body area(s) or organ system(s) and any other symptomatic or related body area(s) or organ system(s)
• Comprehensive - General multi-system examination OR complete examination of a single organ system and other symptomatic or related body area(s)or 8 or more organ system(s)
• Medical decision making that is straightforward OR of low complexity. Documentation needed (2 of 3 below must be met or exceeded):
• Straightforward - Minimal number of diagnoses or management options; None or minimal amount and/or complexity of data to be reviewed; Minimal risk of significant complications, morbidity and/or mortality
• Low complexity - Limited number of diagnoses or management options; Limited amount and/or complexity of data to be reviewed; Low risk of significant complications, morbidity and/or mortality

99222 - 50 minutes (average)

• Comprehensive history. Documentation needed:
• Chief complaint
• Extended history of present illness
• Complete review of systems
• Complete past, family, and social history
• Comprehensive examination. Documentation needed:
• General multi-system examination OR complete examination of a single organ system and other symptomatic or related body area(s)or 8 or more organ system(s)
• Medical decision making that is moderate complexity. Documentation needed (2 of 3 below must be met or exceeded):
• Multiple number of diagnoses or management options
• Moderate amount and/or complexity of data to be reviewed
• Moderate risk of significant complications, morbidity and/or mortality

99223 - 70 minutes (average)

• Comprehensive history. Documentation needed:
• Chief complaint
• Extended history of present illness
• Complete review of systems
• Complete past, family, and social history
• Comprehensive examination. Documentation needed:
• General multi-system examination OR complete examination of a single organ system and other symptomatic or related body area(s)or 8 or more organ system(s)
• Medical decision making that is of high complexity. Documentation needed (2 of 3 below must be met or exceeded):
• Extensive number of diagnoses or management options
• Extensive amount and/or complexity of data to be reviewed
• High risk of significant complications, morbidity and/or mortality