SELECTING THE LEVEL OF E/M SERVICE

The following are step-by-step instructions that guide you through the code selection process when providing services defined by E/M codes. Code selection is made based on the work performed.

Step 1: Select the Category and Subcategory of E/M Service

 This table provides only a partial list of services and their codes. For the full list of E/M codes you will need to refer to the CPT manual.

CATEGORY/SUBCATEGORY	CODE NUMBERS
Office or outpatient services
New patient	99201–99205
Established patient	99211–99215
Hospital observational services
Observation care discharge services	99217
Initial observation care	99218–99220
Hospital inpatient services
Initial hospital care	99221–99223
Subsequent hospital care	99231–99233
Hospital discharge services	99238–99239
Consultations
Office consultations	99241–99245
Inpatient consultations	99251–99255
Emergency department services
Emergency department services	99281–99288
Nursing facility services
Initial nursing facility care	99304–99306
Subsequent nursing facility care	99307–99310
Nursing facility discharge services	99315–99316
Annual nursing facility assessment	99318
Domiciliary, rest home, or custodial care services
New patient	99324–99328
Established patient	99334–99337
Home services
New patient	99341–99345
Established patient	99347–99350
Team conference services
Team conferences with patient/family	99366
Team conferences without patient/family	99367
Behavior change interventions
Smoking and tobacco use cessation	99406–99407
Alcohol and/or substance abuse structured screening and brief intervention	99408–99409
Non-face-to-face physician services
Telephone services	99441–99443
On-line medical evaluation	99444
Basic life and/or disability evaluation services	99450
Work-related or medical disability evaluation services	99455–99456

Step 2: Review the Descriptors and Reporting Instructions for the E/M Service Selected

 Most of the categories and many of the subcategories of E/M services have special guidelines or instructions governing the use of the codes. For example, under the description of initial hospital care for a new or established patient, the CPT manual indicates that the inpatient care level of service reported by the admitting physician should include the services related to the admission that he or she provided in other sites of service as well as in the inpatient setting. E/M services that are provided on the same date in sites other than the hospital and that are related to the admission should not be reported separately.

Examples of Descriptors for CPT Codes Used Most Frequently by Psychiatrists 

99221—Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components: 

• A detailed or comprehensive history 

• A detailed or comprehensive examination 

• Medical decision making that is straightforward or of low complexity Counseling and/or coordination of care with other providers or agencies is provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the problem(s) requiring admission are of low severity. Physicians typically spend 30 minutes at the bedside and on the patient’s hospital floor or unit.

99222—Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components: 

• A comprehensive history 

• A comprehensive examination 

• Medical decision making of moderate complexity Counseling and/or coordination of care with other providers or agencies is provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the problem(s) requiring admission are of moderate severity. Physicians typically spend 50 minutes at the bedside and on the patient’s hospital floor or unit.

99223—Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components: 

• A comprehensive history

• A comprehensive examination 

• Medical decision making of high complexity Counseling and/or coordination of care with other providers or agencies is provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the problem(s) requiring admission are of low severity. Physicians typically spend 70 minutes at the bedside and on the patient’s hospital floor or unit.