What factors are used to level inpatient E/M visits?

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Inpatient E/M visit levels (CPT codes 99221–99233) are determined by three key factors, and documentation must support these elements to select the appropriate level:

1. History

  • Includes the interval history, history of present illness (HPI), review of systems (ROS), and past, family, social history (PFSH).

  • The depth of history (problem-focused to comprehensive) affects the level.

2. Examination

  • Physical exam ranges from a problem-focused exam to a comprehensive exam involving multiple organ systems.

  • The extent of the exam performed influences coding level.

3. Medical Decision Making (MDM)

  • Complexity of MDM is based on:

    • Number and complexity of problems addressed

    • Amount/complexity of data reviewed and analyzed

    • Risk of complications, morbidity, or mortality of patient management

Coding Requirements:

  • To select a specific level, you must meet or exceed two out of three components (History, Exam, MDM) at that level.

  • For example, if History and Exam support Level 3 but MDM is Level 2, you can still bill Level 3.

Additional Notes:

  • Time may be used in certain situations but is less commonly the primary factor for inpatient E/M coding.

  • Documentation must be thorough and reflect the complexity of care.

This multi-factor approach ensures the code accurately reflects the clinical services provided during the inpatient encounter.

Read More

How do you calculate medical decision-making complexity?

Explain the 2021 E/M coding guidelines for office visits.

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