CHAPTER 15
EVALUATION AND MANAGEMENT
(E/M) SERVICES
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Slide 1
Coding for Services
• Your job is to code what is documented in
the medical record
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Slide 2
Your Job
• Optimize—never maximize
– Optimize = “get the most out of”
– Maximize = “to increase or make as great as
possible”
• Accurately report documented services
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Slide 3
A Crime!
• Coding for services not provided
is a CRIME
– Fraud: Billing for services never rendered
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Slide 4
Chapter 15 Reviews
• E/M (Evaluation and Management) section
• Reports physician services
(Cont’d…)
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Slide 5
Chapter 15 Reviews
(…Cont’d)
• Subsections by type of service
• Types of service:
– Office
– Hospital
– Consultations
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Slide 6
Three Factors of E/M Codes
• Place of service
• Type of service
• Patient status
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Slide 7
Place of Service
• Explains setting of service:
– Office
– Emergency Department
– Nursing Home, etc.
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Slide 8
Type of Service
• Physicians provide many types
of services:
– Office visits
– Admissions
– Consultations
– Prolonged Services
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Slide 9
Patient Status
• Four status types:
– New patient
– Established patient
– Outpatient
– Inpatient
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Slide 10
New Patient
• Has not received any professional service
3 years from:
in last _
– The same physician
– From another physician of the exact same
Specialty and subspecialty and in same
group
• New patients more labor intensive for
physician and staff
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Slide 11
Established Patient
• Has received professional services in last
3 years from:
– The same physician or
– Another physician of exact same specialty and
subspecialty in same group
• Medical record available with current,
relevant information
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Slide 12
Outpatient
• One who has not been formally admitted
to a health care facility
– Example: Patient receives service at clinic or
same-day surgery center
– Example: Patient admitted to “observation”
status
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Slide 13
Inpatient
• One who has been formally admitted to a
health care facility (e.g., hospital, nursing
facility, etc.)
• Attending physician dictates:
– Admission orders
–H&P
– Requests consultations
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Slide 14
Levels of E/M Service Based On
1. Nature of the presenting problem (foundation)
2. Skill required to provide service
3. Time spent (if 50% of total time is counseling
or coordination of care)
4. Level of knowledge necessary to treat patient
5. Effort required/assumed
6. Responsibility required
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Slide 15
E/M Levels Are Divided Based On
• Key Components (KC)
• Contributory Factors (CF)
• Every encounter contains varying amount
of KC and CF
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Slide 16
Encounters
• More of each component/factor
– Higher level of service
• Less of each component/factor
– Lower level of service
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Slide 17
Key Components
• History
• Examination
• Medical decision making
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Slide 18
Contributory Factors
• Counseling
• Coordination of care
• Nature of presenting problem
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Slide 19
Four Elements of a History
• Chief Complaint (CC)
• History of Present Illness (HPI)
• Review of Systems (ROS)
• Past, Family, and/or Social History (PFSH)
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Slide 20
Chief Complaint (CC)—
Subjective
• Reason for encounter
– Patient’s current complaint
– Usually presented in patient’s own words
• Documented in medical record for each
encounter
• Required for all levels of service
• May not be stated as “CC” but is inferred
from documentation
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Slide 21
History of Present Illness (HPI)—
Subjective
• Description of development of current
illness
– e.g., date of onset
• Patient describes HPI
• If patient cannot answer for themselves, a
parent, guardian, or other may provide
• Eight elements in HPI
• Provider must document
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Slide 22
Physician and Patient
Dialogue
• Development of a CC of abdominal pain:
• “Started Thursday night and was mild.
During night, it got worse. Friday morning
I went to work, but had to leave because
pain got so bad.”
(Cont’d…)
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Slide 23
Physician and Patient
Dialogue
(…Cont’d)
• Location—specific location of pain
• “Pain was in lower left-hand side,
a little toward back.”
(Cont’d…)
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Slide 24
Physician and Patient
Dialogue
(…Cont’d)
• Quality—Is pain sharp, dull, pressure,
burning? (a sensation)
• “Pain is really sharp and constant.”
(Cont’d…)
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Slide 25
Physician and Patient
Dialogue
(…Cont’d)
• Severity—Is pain intense, moderate, mild?
– On a scale of 1-10 may be stated
• “Pain is terrible, worst pain I have ever
had.” (intense)
(Cont’d…)
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Slide 26
Physician and Patient
Dialogue
(…Cont’d)
• Duration—How long has pain been
present?
• “Pain has been going on now for 3 days.”
(Cont’d…)
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Slide 27
Physician and Patient
Dialogue
(…Cont’d)
• Timing—Is pain present all the time, or
does it come and go?
• “Pain just continues. It just doesn’t go
away.”
(Cont’d…)
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Slide 28
Physician and Patient
Dialogue
(…Cont’d)
• Context—When does it hurt most?—Is
there a correlation to a specific activity
(e.g., climbing stairs)?
• “Pain is just there; it doesn’t matter what I
am doing.”
(Cont’d…)
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Slide 29
Physician and Patient
Dialogue
(…Cont’d)
• Modifying factors—Does anything make it
better or worse?
• “Nothing I do makes it any better or any
worse.”
• Aspirin taken, no relief.
(Cont’d…)
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Slide 30
Physician and Patient Dialogue
(…Cont’d)
• Associated signs and symptoms relating
to presenting problem(s)—Does anything
else feel different when pain is present?
• “Yes, I have nausea when pain is worst.”
(Cont’d…)
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Slide 31
Review of Systems (ROS)—Subjective
• Organ systems
– Respiratory system
– Cardiovascular system
• There are 14 elements in ROS
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Slide 32
Extent of ROS depends on CC
• Example: Do not usually review musculoskeletal
system for CC of chest pain
• Example: A patient who has sustained trauma
from an auto accident and cannot discern
difference
• Medical necessity for the number of OSs
inventoried must be implied or documented
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Slide 33
Systems in ROS
• Constitutional—General, Fever, Weight
Loss or Gain
• Eyes—Organ System (OS)
• Ears, Nose, Mouth, Throat (OS)
• Cardiovascular (OS)
(Cont’d…)
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Slide 34
Systems in ROS
(…Cont’d)
• Respiratory (OS)
• Gastrointestinal (OS)
• Genitourinary (OS)
• Musculoskeletal (OS)
• Integumentary (OS)
(Cont’d…)
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Slide 35
Systems of ROS
(…Cont’d)
• Neurologic (Neurological) (OS)
• Psychiatric (OS)
• Endocrine (OS)
• Hematologic/Lymphatic (OS)
• Allergic/Immunologic (OS)
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Slide 36
Past, Family, and/or Social
History (PFSH)
• Past and Social History contains relevant
information about past:
– Major illnesses/injuries
– Operations
– Hospitalizations
– Allergies
– Immunizations
– Dietary status
(Cont’d…)
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Slide 37
Past and Social History
(…Cont’d)
• Social history contains relevant
information about:
– Sexual history
– Other relevant social factors
(Example: Employment)
• Past-present medications
• Social tobacco/alcohol use
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Slide 38
Family History
• Health status of family members:
– Parents
– Siblings
– Children
• Family history items related to CC
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Slide 39
History Levels
Four history levels:
1. Problem focused
2. Expanded problem focused
3. Detailed
4. Comprehensive
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Slide 40
Problem Focused History
• Brief history focused on CC
• Brief HPI
• No ROS
• No PFSH
• Brief history includes 1-3 of the eight
elements of the HPI
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Slide 41
Expanded Problem Focused History
• Brief history focused on CC
• Brief HPI
– Less than 3 of 8 elements or 1-2 chronic
problems
• ROS as it pertains to Presenting Problem
• No PFSH
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Slide 42
Detailed History
• Extended history
• Extended HPI
– HPI:
• 4 or more of 8 elements
• 3 or more chronic conditions
• Extended ROS
• Pertinent PFSH
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Slide 43
Comprehensive History
• Extended history
• Extended HPI
• Complete ROS
• Complete PFSH
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Slide 44
Summary of Elements Required for
Each Level of History
Figure: 15.4
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Slide 45
Examination—Objective (Hands-on)
• Four levels of examination:
– Problem Focused
– Expanded Problem Focused
– Detailed
– Comprehensive
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Slide 46
Problem Focused
Examination
• Affected body area and/or organ system
– 10 Body areas (BOs) (1995 Guidelines)
– 12 Organ systems (OSs) (1995 Guidelines)
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Slide 47
Expanded Problem Focused
Examination
• Limited examination
• Affected BO and/or OS
• Other related BO(s) and/or OS(s)
– Often vitals or general appearance of
patient
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Slide 48
Detailed Examination
• Extended examination of affected BO(s)
and/or related OS(s)
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Slide 49
Comprehensive Examination
• Complete single specialty or complete
multisystem examination
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Slide 50
Summary of Elements Required for
Each Level of Examination
Figure: 15.5
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Slide 51
Remember
• Extent of examination depends on needs
of patient and expert judgment of
physician
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Slide 52
“If It Isn’t Documented, It Didn’t Happen.”
–Wise Coder
• “It may have happened, but you can’t bill
for it unless you documented it.”
–Wise Coder to Physician
• Extent of examination must be
documented in medical record
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Slide 53
Medical Decision Making
Complexity (MDM)
• Level of MDM is significantly different for:
– Patient A chest cold
– Patient B severe chest pain
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Slide 54
Three Elements of Medical
Decision Making (MDM)
1. Number of diagnoses or management
options
• Minimal, limited, moderate, or extensive
(Cont’d…)
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Slide 55
Elements of MDM
(…Cont’d)
2. Amount and/or complexity of data to be
reviewed by physician
• Minimal, limited, moderate, or extensive
(Cont’d…)
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Slide 56
Elements of MDM
(…Cont’d)
3. Risk of complications or death (morbidity
or mortality)
• Minimal, low, moderate, or high
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Slide 57
Four Levels of MDM Complexity
• Straightforward
• Low
• Moderate
• High
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Slide 58
Straightforward MDM
• Number of diagnoses or management
options: Minimal
• Amount and/or complexity of data:
Minimal/None
• Risk of complications or death: Minimal
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Slide 59
Low Complexity MDM
• Number of diagnoses or management
options: Limited
• Amount and/or complexity of data: Limited
• Risk of complications or death: Low
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Slide 60
Moderate Complexity MDM
• Number of diagnoses or management
options: Multiple
• Amount and/or complexity of data:
Moderate
• Risk of complications or death: Moderate
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Slide 61
High Complexity MDM
• Number of diagnoses or management
options: Extensive
• Amount and/or complexity of data:
Extensive
• Risk of complications or death: High
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Slide 62
Management Options
• Based on number of possible diagnoses
(definitive or differential) and/or various
ways condition can be treated
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Slide 63
Data Reviewed/Ordered
• Laboratory, radiology; any test/procedure
results are documented in medical record
(Cont’d…)
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Slide 64
Data Reviewed
(…Cont’d)
• A review of results should be documented
in medical record
– “Hemoglobin within normal limits”
– “Chest x-ray, negative”
(Cont’d…)
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Slide 65
Data Reviewed
(…Cont’d)
• Old medical records (data) from others
may be requested and reviewed
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Slide 66
Risks
• Risks of morbidity (poor outcome),
complications, or mortality (death)
with problem and/or treatment
(Cont’d…)
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Slide 67
Risks
(…Cont’d)
• Other diseases or factors that
affect risks
• Diabetes
• Extreme age
(Cont’d…)
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Slide 68
Risks
(…Cont’d)
• Urgency relates to risks
– Myocardial infarction
– Ruptured appendix
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Slide 69
Four Risk Levels
1. Minimal
2. Low
3. Moderate
4. High
(Cont’d…)
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Slide 70
Risk Levels
(…Cont’d)
1. Minimal: Self-limited
• Wasp bite
(Cont’d…)
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Slide 71
Risk Levels
(…Cont’d)
2. Low: Several minimal levels or one level
that is more than minimal
• Multiple wasp bites
(Cont’d…)
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Slide 72
Risk Levels
(…Cont’d)
3. Moderate:
• One or more chronic illnesses
– Diabetes
• Two or more stable but chronic illnesses
– Controlled high blood pressure and diabetes
(Cont’d…)
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Slide 73
Moderate Risk Level
(…Cont’d)
• Undiagnosed condition with
unknown prognosis
• Breast lump
• Acute illness
• Pneumonia
(Cont’d…)
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Slide 74
Risk Levels
(…Cont’d)
4. High:
• One or more chronic illnesses with current
severe exacerbation
– Malignant hypertension and uncontrolled
diabetes
(Cont’d…)
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Slide 75
High Risk Level
(…Cont’d)
• Illness or injury that is life-threatening,
such as:
– Myocardial infarction
– Cardiac arrest
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Slide 76
Summary of Elements Required for
Each Level of MDM
Only 2 of 3 categories must meet or exceed the element
stated to assign the level
Figure: 15.6
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Slide 77
Review of Three Key
Components
• History
• Examination
• Medical Decision Making
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Slide 78
Key Component 1: History
• CC, HPI, ROS, PFSH
• Four Levels of History:
– Problem Focused
– Expanded Problem Focused
– Detailed
– Comprehensive
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Slide 79
Key Component 2:
Examination
• Objective examination of patient
• Four Levels of Examination:
– Problem Focused
– Expanded Problem Focused
– Detailed
– Comprehensive
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Slide 80
Key Component 3: MDM
• Number of diagnoses or management
options
• Data to be reviewed
• Risks from current encounter to next visit
(Cont’d…)
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Slide 81
Four Levels of MDM
(…Cont’d)
• Straightforward
• Low
• Moderate
• High
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Slide 82
Other Factors
• Three other factors are considered in
establishing level of service:
– They are Contributory Factors
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Slide 83
Contributory Factors
1. Counseling
2. Coordination of Care
3. Nature of Presenting Problem
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Slide 84
1. Counseling—face-to-face
• Provided to patient or family members
• Discussion of diagnosis, test results,
impressions, recommendations
• Medical documentation must support that
more than 50% of visit was counseling
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Slide 85
2. Coordination of Care—
face-to-face
• Work done on behalf of patient by
physician to provide care
– Example: Arrangements made for admission
to a rehabilitation hospital or nursing facility
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Slide 86
3. Nature of Presenting Problem
• Type of problem patient presents
to physician with
• Foundation upon which the key
components are factored
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Slide 87
Types of Presenting Problem
• Minimal
• Self-limiting
• Low
• Moderate
• High
(Cont’d…)
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Slide 88
Minimal Presenting Problem
(…Cont’d)
• May not require a physician
– Example: A dressing change or removal
of an uncomplicated suture
(Cont’d…)
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Slide 89
Self-Limiting Presenting Problem
(…Cont’d)
• Self-limiting problems are minor and with a
good outcome predicted
– Example: Sore throat or a slightly irritated skin
tag
(Cont’d…)
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Slide 90
Low Presenting Problem
(…Cont’d)
• Without treatment, low risk
• Example: A middle age, healthy male with
an upper respiratory infection
(Cont’d…)
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Slide 91
Moderate Presenting Problem
(…Cont’d)
• Without treatment, moderate risk
– Example: An elderly male with pneumonia
(Cont’d…)
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Slide 92
High Presenting Problem
(…Cont’d)
• Without treatment, high risk
– Example: An elderly male in very poor health
with severe pneumonia
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Slide 93
Time
• Direct face-to-face: Physician and patient
together
– Example: Clinic visit or at bedside in hospital
• Use to assign time-based codes, beginning and
ending times documented in medical record
• Total time spent and indication that >50% was
counseling/coordination of care
(Cont’d…)
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Slide 94
Time
(…Cont’d)
• Unit/Floor: Time spent by physician on
patient’s floor or unit, also at patient’s
bedside
– Example: Reviewing patient records or at
chart desk and then with patient
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Slide 95
E/M Code
Figure: 15.7
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Slide 96
Use of E/M Code
• Codes are grouped by type and place of
service
– Consultation
– Office visit
– Hospital admission
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E/M Codes
• Different codes for various levels of
service
– 99201-99205 services to new patient in office
or other outpatient setting
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Slide 98
Established Patient
• 99211, may not require a physician
• No such code in New Patient category;
all new patients are seen by physician
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Slide 99
Hospital Observation Status
• Not officially admitted to a hospital
• Patient not ill enough to admit but is too ill
not to be monitored
(Cont’d…)
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Slide 100
Hospital Observation Status
(…Cont’d)
• Read notes at beginning of subsection
• Observation services are not codes for
inpatient services
(Cont’d…)
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Slide 101
Hospital Observation
(…Cont’d)
• Observation admission can only be
reported for first day of service by the
admitting physician
(Cont’d…)
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Slide 102
Hospital Observation
(…Cont’d)
• When patient admitted with observation
status and discharged on same day:
– Use code from 99234-99236 (Observation or
Inpatient Care Services category)
– Medicare has time constraints for these codes
(Cont’d…)
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Slide 103
Hospital Observation
(…Cont’d)
• Patient in hospital overnight for
observation but less than 48 hours:
– 1st day: 99218-99220 (Initial Observation
Care)
– 2nd day: 99217 (Observation Care Discharge
Services)
(Cont’d…)
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Slide 104
Hospital Observation
(…Cont’d)
• If observation stay longer than 48 hours:
– 1st day: 99218-99220
(Initial Observation Care)
– 2nd day: 99224-99226
(Subsequent Observation Care)
– 3rd day: 99217
(Observation Care Discharge)
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Slide 105
Initial Observation Care
• Beginning of observation care service
• Does not require a specific hospital unit;
can be a regular bed
– Status specified as “observation”
(Cont’d…)
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Slide 106
Initial Observation Care
(…Cont’d)
• Services immediately prior to admission
bundled into observation service
– Example: Office visit prior to observation,
bundled into observation service if performed
on same date of service
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Hospital Inpatient Services
• Formally admitted to a hospital setting
• Total (all day and night) on a given date
of service
• Partial (all day and no night, or all night
and no day, or a variation)
• Patient starting an observation, then
admitted: services are bundled into Initial
Hospital Service (99221-99223)
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Slide 108
Types of Physician Status
• Attending: Primary or admitting physician
• Consultant: Physician whose opinion
and/or advice requested by another
physician
– Specific criteria required
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Slide 109
Types of Care
• Concurrent care given to patient by more
than one physician
– Example: Pulmonologist and cardiologist both
treating patient for different conditions at
same time
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Slide 110
Two Types of Hospital Inpatient Services
1. Initial
2. Subsequent
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Slide 111
1. Initial Hospital Care
• First service includes admission
– Initial paperwork
– Initial plans and orders
• Used only once for each admission by the
admitting physician
• Other physicians would bill consultation or
subsequent hospital care, as appropriate
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Slide 112
2. Subsequent Hospital Care
• After initial service
• Physician reviews patient’s interval
progress using documentation, information
received from nursing staff, examination of
patient
• 2 of the 3 key components met
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Slide 113
Hospital Discharge Services
• Final day of hospital stay when patient was in
hospital for more than 1 day
• Documentation indicates final patient status
• Codes based on time
– Time does not need to be continuous
• Beginning and ending time or total time must be
documented to assign extended discharge code
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Slide 114
Final Status of Patient
• Condition
• Medications
• Plan for return to physician
• How hospital stay progressed
• Discharged to home, nursing facility, etc.
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Slide 115
Unique to Discharge Codes
• Only attending physician can use a
discharge code
• Code is based on time spent in service
• Beginning and ending time must be
documented, total time spent or use
lowest level code
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Slide 116
Consultation Services
(99241-99255)
• One physician requests another
physician’s opinion
• Either inpatient or outpatient
(Cont’d…)
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Slide 117
Consultation Services
(…Cont’d)
• Reported as outpatient or inpatient
consultation
• Only one consult by a consultant per
hospital admission
• Consultant provides report of
opinion/advice
• Documented in medical record
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Slide 118
Third-Party Payer Consultations
• Request to confirmation:
– Past medical treatment
– Current condition
– Payers may request prior to approving procedure
• Bill using inpatient or outpatient consult codes
• Apply -32 modifier (mandated service)
• Outpatient consultations include those provided in ED
• As of January 1, 2010, payment for Medicare consults are no longer
reimbursed.
– Report with E/M codes (inpatient or outpatient)
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Slide 119
Emergency Department (ED)
Services (99281-99288)
• Codes for new and established patients
• Qualified as ED (AKA: ER): must be open
24 hours a day, unscheduled visits
• Usually provided by ED staff
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Slide 120
Critical Care and ED Codes
• ED services often require additional codes from
Critical Care Services
– Example: multiple organ failure
• Critical Care Services are provided to patients in
life-threatening situations
• Type of service (e.g., Critical Care) will depend
on condition present on arrival in ED
• Codes are time based
– Total time less than 30 minutes, reported with
appropriate E/M code
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Slide 121
Critical Care Services
(99291, 99292)
• 99291 and 99292 are used to report length of
time a physician spends caring for critically ill
patient
• 99291: 30-74 minutes
• 99292: each additional 30 minutes
• Over 24 months of age (outpatient)
• Over 71 months of age (inpatient)
• Total time under 30 minutes reported with E/M
code
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Slide 122
Nursing Facility Services
(99304-99318)
• Non-hospital settings with
professional medical staff
– Provide continuous health care services
to patients who are not acutely ill
• Formerly known as Skilled Nursing Facility
(SNF), Intermediate Care Facility (ICF), and
Long-Term Care Facility (LTCF)
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Slide 123
Comprehensive Nursing Facility
Assessment
• Provided at time of admission (initial visit
by physician) (99304-99306)
• Provided periodically during stay as
established by facility regulations (99318)
• Subsequent Nursing Facility Care codes
used if patient stable or condition
unchanged (99307-99310)
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Slide 124
Domiciliary, Rest Home, or
Custodial Care Services (99324-99337)
• Health care services are not available
on site
• Types of services provided are lodging,
meals, supervision, personal care, leisure
activities
• Residents cannot live independently
• Codes for new and established patients
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Slide 125
Domiciliary, Rest Home, or
Home Care Plan Oversight Services
(99339, 99340)
• Applies to anyone not in home health,
hospice, or nursing facility
• Reported once per month
• Codes based on time
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Slide 126
Home Services (99341-99350)
• Care provided in patient’s home
• Services based on history, physical
examination, and MDM
• Codes for new or established patients
• A “home” is the patient’s private residence
(not an assisted care facility)
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Slide 127
Prolonged Services
(99354-99359)
• Time-based codes for direct and nondirect services
• Codes for first 30-74 minutes
• Codes for each additional 30 minutes
• If less than 30 minutes, do not report
service as prolonged
– Add-on code
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Slide 128
Physician Standby Service
• Physician not caring for other patient to
use this code (99360)
• Physician standing by only for that patient,
if needed
• Even if no care was provided to patient
during standby time, report and bill service
• Must be documented in medical record
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Slide 129
Case Management Services
(99363-99368)
• Used to report coordination of care with other
health professionals and anticoagulant
management
• Anticoagulant Management (99363, 99364)
– Outpatient management of warfarin therapy
• 1st 90 days, subsequent 90 days
– Any period less than 60 days is not reported
(Cont’d…)
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Slide 130
Case Management Services
(…Cont’d)
• Medical Team Conferences (99366-99368)
– Face-to-Face with patient and/or family―99366
• Participation by nonphysician qualified health professional
30 minutes or more
– Without patient and/or family―99367
• Participation by physician 30 minutes or more
– Without patient and/or family―99368
• Participation by nonphysician qualified health professional
30 minutes or more
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Slide 131
Care Plan Oversight Services
(99374-99380)
• Used to report physician supervision of
patient care under home, domiciliary, or
equivalent environment
• Reported for 30-day period
• Reported in increments of
– 15-29 minutes
– 30 minutes or more
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Slide 132
Preventive Medicine Services
(99381-99429)
• Used to report services when patient is not
currently ill
– Example: Annual checkup
• Codes divided on new or established
patient status, and patient age
(Cont’d…)
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Slide 133
Preventive Medicine Services
(…Cont’d)
• If significant problem is encountered
during preventive examination:
– E/M code also reported
– Modifier -25 added to E/M code
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Slide 134
Individual and Group Counseling
(99401-99412)
• Patient is seen specifically to promote health
– Example: Diet, exercise program
(Cont’d…)
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Slide 135
Individual and Group Counseling
(…Cont’d)
• Codes based on
– Time
– Individual or group
– Physician review of assessment data
• Behavior change interventions for
individuals
– Smoking, tobacco, alcohol
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Slide 136
Non-Face-to-Face Physician
Services (99441-99444) and Special E/M
Services (99450-99456)
• 99441-99443 report telephone E/M
services
• 99444 reports online E/M services
• Codes 99450-99456 are used for services
provided for life or disability insurance
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Slide 137
Newborn Care and
Neonatal/Pediatric Critical Care Services
• Newborn Care (99460-99463)
• Delivery/Birthing Room Attendance (99464, 99465)
• Pediatric Critical Care Patient Transport (99466, 99467)
• Inpatient Neonatal Critical Care Services (99468, 99469)
• Inpatient Pediatric Critical Care Services (99471-99476)
• Initial and Continuing Intensive Care Services (9947799480)
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Slide 138
Newborn Care
(99460-99463)
• Initial and subsequent care in/other than
hospital or birthing center
– For normal newborn infant
– Per day, for E/M services
• 99463, initial hospital/birthing center when
admission and discharge is same day
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Slide 139
Delivery/Birthing Room
Attendance/Resuscitation (99464-99465)
• 99464, attendance at delivery
– Documented request by attending in medical
record
– Provides initial stabilization
• 99465, resuscitation and ventilation
– Intubation (31500) not included
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Slide 140
Neonatal and Pediatric Critical Care
Services Subsection (99466-99480)
• Pediatric Critical Care Patient Transport
– 99466, 99467
• First 30-74 minutes
• Each additional 30 minutes
• Reports interfacility transport
– Face-to-face service
• Critically ill or injured patient
– 24 months or younger
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Slide 141
Inpatient Neonatal Critical
Care Services
• 99468, 99469
• Divided by
– initial day
– subsequent day
• Critically ill neonate
– Age 28 days or younger
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Slide 142
Inpatient Pediatric Critical
Care Services
• 99471-99476
• Inpatient services
• Divided by age
– 29 days-24 months
– 2-5 years
• Subdivided by day
– Initial
– Subsequent
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Slide 143
Initial and Continuing
Intensive Care Services
•
•
•
•
99477-99480
Hospital Care
99477 for neonate 28 days of age or younger
99478-99480 divided by birth weight
– very low birth weight (VLBW) ≤1500 grams
(≤ 3.3 pounds)
– low birth weight (LBW) 1500-2500 grams
(3.3-5.5 pounds)
– normal birth weight 2501-5000 grams
(5.51-11.01 pounds)
• Subdivided on day
– Initial
– Subsequent
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Slide 144
Other E/M Services
(99499)
• 99499 is seldom used
– Requires a written report with submission
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Slide 145
Conclusion
CHAPTER 15
EVALUATION AND MANAGEMENT
(E/M) SERVICES
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Slide 146