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Documentation Guidelines for CPT Evaluation and Management Services                         

Inpatient Coding

Consultations - Initial Inpatient (meet or exceed all 3 elements)
History
Exam
Decision Making
Code
Problem focused:
CC, HPI 1-3
Problem focused:1 body system Straight forward:Dx = Min;Data = Min/0; Risk = Min 99251
Expanded problem focused:
CC, HPI 1-3, ROS 1
Expanded problem focused:affected area & others Straight forward:Dx = Min;Data = Min/0; Risk = Min 99252
Detailed:
CC, HPI 4,ROS 2-9, PFSH 1
Detailed:7 systems Low:Dx = Ltd;Data = Ltd; Risk = Low 99253
Comprehensive:
CC, HPI 4+,ROS 10, PFSH 3
Comprehensive:8 systems Moderate:Dx = Multi,Data = Mod, Risk = Mod 99254
Comprehensive:
CC, HPI 4+,ROS 10+, PFSH 3
Comprehensive:8 systems High:Dx = Ext,Data = Ext, Risk = High 99255

Inpatient - Initial Visit (meet or exceed all 3 elements)
History
Exam
Decision Making
Code
Detailed:CC, HPI 4,ROS 2-9, PFSH 1 Detailed:7 systems Straight forward or low:Dx = Min;Data = Min; Risk = Min 99221
Comprehensive:CC, HPI 4+,ROS 10, PFSH 3 Comprehensive:8 systems Moderate:Dx = Multi,Data = Mod, Risk = Mod 99222
Comprehensive:CC, HPI 4+,ROS 10+, PFSH 3 Comprehensive:8 systems High:Dx = Ext,Data = Ext, Risk = High 99223

Inpatient - Subsequent Visit (meet or exceeds 2 of 3 elements)
History
Exam
Decision Making
Code
Problem focused:CC, HPI 1-3 Problem focused:1 body system Low or straight forward:Dx = Min/Ltd;Data = Min/Ltd; Risk = Min/Ltd 99231
Expanded problem focused:CC, HPI 1-3, ROS 1 Expanded problem focused:affected area & others Moderate:Dx = Multi;Data = Multi; Risk = Mod 99232
Detailed:CC, HPI 4,ROS 2-9, PFSH 1 Detailed:7 systems High:Dx = Ext;Data = Ext; Risk = High 99233

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