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

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.