Article Figures & Data
Tables
- Table 1
Elements required for history
Type of history CC HPI PFSH ROS Problem focused Required Brief n/a n/a Expanded problem focused Required Brief n/a Problem pertinent
(one system)Detailed Required Extended Pertinent (1 of 3) Extended (2–9 systems) Comprehensive Required Extended Complete (3 of 3) Complete (10 systems) CC, chief complaint; HPI, history of present illness; PFSH, past, family, and/or social history; ROS, review of systems.
- Table 2
1997 documentation guidelines: examination
Type of examination Number of organ system or body areas Description Problem-focused At least one organ system One to five elements identified by a bullet in at least one organ system Expanded problem-focused At least one organ system At least six elements identified by a bullet in at least one organ system Detailed At least 2 elements each in six organ systems
OR
At least 12 elements in two or more organ systems‘2 in 6’ At least two elements identified by a bullet in at least six organ systems
‘12 in 2’ Alternatively, may include at least 12 elements identified by a bullet in two or more organ systemsComprehensive Two elements from at least nine organ systems or complete examination of single organ system At least nine organ systems or complete examination of single organ system - Table 3
Minimum requirements for highest-level billing in a new patient (inpatient/outpatient)
Sections 1995 1997 CC 
HPI Four elements or status update of three chronic conditions Four elements or status update of three chronic conditions PFSH One element from all three categories One element from all three categories ROS One element from least 10 of 14 systems One element from least 10 of 14 systems PE One element from at least eight organ systems
OR
One complete single specialty system examinationAt least two bullets in at least nine organ systems Always document why it is not possible to obtain information regarding a specific element of history or examination to receive credit for addressing that element, body area or organ system.
CC, chief complaint; HPI, history of present illness; PE, physical examination; PFSH, past, family, and/or social history; ROS, review of systems.
- Table 4
Current codes for office encounters
New patient visit Typical time (minutes) Established
patient visitTypical time (minutes) 99201 10 99211 5 99202 20 99212 10 99203 30 99213 15 99204 45 99214 25 99205 60 99215 40 - Table 5
Initial hospital service codes
Level E/M code History Physical examination MDM Time 1 99221 (1.92 wRVU) Detailed Detailed Straightforward/low 30 min. 2 99222 (2.61 wRVU) Comprehensive Comprehensive Moderate 50 min. 3 99223 (3.86 wRVU) Comprehensive Comprehensive High 70 min. E/M, evaluation and management; MDM, medical decision making; wRVU, work relative value unit.
- Table 6
Inpatient hospital service codes (daily visits)
Level E/M code History Physical examination MDM Time 1 99231
(0.76 wRVU)Focused Focused Straightforward/low 15 2 99232
(1.39 wRVU)Expanded Expanded Moderate 25 3 99233
(2.0 wRVU)Detailed Detailed High 35 E/M, evaluation and management; MDM, medical decision making; wRVU, work relative value unit.
- Table 7
Critical care time coding guide
Codes Less than 30 min 99232 or 99233 or other appropriate E/M code 30 min to 74 min 99291×1 75 min to 104 min 99291×1 and 99292×1 105 min to 134 min 99291×1 and 99292×2 135 min to 164 min 99291×1 and 99292×3 E/M, evaluation and management.
