99201 Problem Focused
99202 Expanded Problems
99203 Detailed, low complexity
99204 Comprehensive, moderate complexity
99205 Comprehensive, high complexity
99211 Problem Focused
99212 Expanded Problems
99213 Detailed, low complexity
99214 Comprehensive, moderate complexity
99215 Comprehensive, high complexity
Hospital Observation Serices - Initial New or Established Patient
99218 Detailed, low complexity
99219 Comprehensive, moderate complexity
99220 Comprehensive, high complexity
Hospital Inpatient Services - Initial Hospital Care - New or Established Patient
99221 Detailed, low complexity
99222 Comprehensive, moderate complexity
99223 Comprehensive, high complexity
Hospital Inpatient Services - Subsequent Hospital Care
99231 Problem focused, low complexity
99232 Expanded problem focused, moderate complexity
99233 Detailed, high complexity
Outpatient Consultation - New or Established
99241 Problem Focused
99242 Expanded Problems
99243 Detailed, low complexity
99244 Comprehensive, moderate complexity
99245 Comprehensive, high complexity
Inpatient Consultation - New or Established
99251 Problem Focused
99252 Expanded Problems
99253 Detailed, low complexity
99254 Comprehensive, moderate complexity
99255 Comprehensive, high complexity
Emergency Department Services - New or Established
99281 Problem focused
99282 Expanded problem focused
99283 Expand problem focused, low complexity
99284 Detailed, moderate complexity
99285 Comprehensive, high complexity
History of Present Illness (HPI)
Review of Systems (ROS)
Past Medical History, Family Medical History, Social History (PFSH)
Body areas recognized
* Head, including face
* Chest, including breasts and axillae
* Genitalia, groin, buttocks
* Back, including spine
* Each extremity
Organ systems recognized
* Constitutional (height, weight, blood pressure, physical appearance) [1995 guidelines]
* Ears, nose, mouth, and throat
Coding based on time
New patient is defined as a patient who has not been seen by you within the past three years and has not been seen by another provider in your specialty group.
Established patient has been seen by you within the past three years or was seen by another provider in your specialty group.
Consults: request for a consultation from an appropriate source and the need for consultation must be documented in the patient's medical record. Consultant must provide written report of his/her findings to the referring physician.
Post-Operative Exam codes (within 90 day global period)
Post-Operative Exam Codes (after 90 day global period)
* -24 applies to an unrelated E&M service provided during the postoperative (or global) period by a single physician.
* -79 applies to an unrelated procedure performed during the global period, rather than an unrelated E&M service.
* -25 applies when a significant, separately identifiable E&M service is performed by a single physician on the same day of another procedure or other service. This must be clearly documented in your note.
* -51 applies when multiple procedures or surgeries are performed during a single visit.
* -50 represents bilateral procedures were performed.
* -53 represents a discontinued procedure.
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