ESTABLISHED PATIENT

99211—This code is used for a service that may not require the presence of a physician. Presenting problems are minimal, and 5 minutes is the typical time that would be spent performing or supervising these services.

99212—Two of the three following components are required:

• Problem-focused history 

• Problem-focused examination 

• Medical decision making that is straightforward 

Presenting problem(s): Self-limited or minor 

Typical time: 10 minutes face-to-face with patient and/or family

99213—Two of the three following components are required:

• Expanded problem-focused history

• Expanded problem-focused examination 

• Medical decision making of low complexity

Presenting problem(s): Low to moderate severity

Typical time: 15 minutes face-to-face with patient and/or family 

99214—Two of the three following components are required: 

• Detailed history 

• Detailed examination 

• Medical decision making of moderate complexity 

Presenting problem(s): Moderate to high severity 

Typical time: 25 minutes face-to-face with patient and/or family

99215—Two of the three following components are required:

• Comprehensive history

• Comprehensive examination 

• Medical decision making of high complexity

Presenting problem(s): Moderate to high severity 

Typical time: 40 minutes face-to-face with patient and/or family

Hospital Observational Services

OBSERVATION CARE DISCHARGE SERVICES 

99217—This code is used to report all services provided on discharge from “observation status” if the discharge occurs after the initial date of “observation status.” 

INITIAL OBSERVATION CARE

99218—The three following components are required:

• Detailed or comprehensive history

• Detailed or comprehensive examination 

• Medical decision making of straightforward or of low complexity

Presenting problem(s): Low severity

Typical time: None listed

99219—The three following components are required:

 • Comprehensive history 

• Comprehensive examination 

• Medical decision making of moderate complexity 

Presenting problem(s): Moderate severity 

Typical time: None listed 

99220—The three following components are required: 

• Comprehensive history 

• Comprehensive examination 

• Medical decision making of high complexity 

Presenting problem(s): High severity 

Typical time: None listed