Initial Hospital E/M Services (Codes 99221 - 99223): Overview of Key Components

This Comparative Billing Report (CBR) focuses on physicians who submit claims for Initial Hospital E/M Services CPT® Codes 99221–99223. CBR information is one of the many tools used to assist individual providers to become proactive in addressing potential billing issues and performing internal audits to ensure compliance with Medicare guidelines.

For your personalized Initial Hospital E/M Services CPT ®99221–99223 eCBR results Log on to eServices.

The key components of E/M including those services billed for initial hospital care are:

1. History;
2. Examination; and
3. Medical decision-making

Note: When billing initial hospital care, all three key components must be fully documented in order to bill. When counseling and/or coordination of care dominates (more than 50 percent) the physician/patient and/or family encounter (at the bedside and floor/unit time in the hospital), then time may be considered the key or controlling factor to qualify for a particular level of E/M services. The extent of such time must be documented in the medical record.

Initial Hospital E/M Services (CPT® Codes 99221–99223) Documentation Requirements

99221 — 30 Minutes (average)
Detailed or comprehensive history. Documentation needed:

• Chief complaint
• Extended history of present illness
• Detailed — Extended review of systems; Pertinent past, family and or social history
• Comprehensive — Complete review of systems; Complete past, family, and social history

Detailed or comprehensive examination. Documentation needed:

• Detailed — Extended examination of the affected body area(s) or organ system(s) and any other symptomatic or related body area(s) or organ system(s)
• Comprehensive — General multi-system examination OR complete examination of a single organ system and other symptomatic or related body area(s)or eight or more organ system(s)

Medical decision making that is straightforward or of low complexity. Documentation needed (two of three below must be met or exceeded):

• Straightforward — Minimal number of diagnoses or management options; None or minimal amount and/or complexity of data to be reviewed; Minimal risk of significant complications, morbidity and/or mortality
• Low complexity — Limited number of diagnoses or management options; Limited amount and/or complexity of data to be reviewed; Low risk of significant complications, morbidity and/or mortality

99222 — 50 Minutes (average)

Comprehensive history. Documentation needed:

• Chief complaint
• Extended history of present illness
• Complete review of systems
• Complete past, family, and social history

Comprehensive examination. Documentation needed:

• General multi-system examination OR complete examination of a single organ system and other symptomatic or related body area(s)or eight or more organ system(s)

Medical decision making that is moderate complexity. Documentation needed (two of three below must be met or exceeded):

• Multiple number of diagnoses or management options
• Moderate amount and/or complexity of data to be reviewed
• Moderate risk of significant complications, morbidity and/or mortality

99223 — 70 Minutes (average)
Comprehensive history. Documentation needed:

• Chief complaint
• Extended history of present illness
• Complete review of systems
• Complete past, family and social history

Comprehensive examination. Documentation needed:

• General multi-system examination OR complete examination of a single organ system and other symptomatic or related body area(s)or eight or more organ system(s)

Medical decision making that is of high complexity. Documentation needed (two of three below must be met or exceeded):

• Extensive number of diagnoses or management options
• Extensive amount and/or complexity of data to be reviewed
• High risk of significant complications, morbidity and/or mortality

Education Resources
The Provider Outreach and Education (POE) team has published an educational article to address the issues pertinent Initial Hospital E/M Services CPT ® Codes 99221–99223 issues. Your practice is being advised to review article Initial Hospital Services.

Methods
The metrics reviewed in this CBR are the proportion of billing for each HCPCS code in the grouping with comparisons done to peers within the state and jurisdiction. This report is an analysis of Medicare Part B claims extracted from the Palmetto GBA data warehouse. The analysis shows the portions of your Initial Hospital E/M Services CPT ® Codes 99221–99223 claims at each level compared to your peers in JJ.