HOSPITAL MEDICINE
CODING GUIDELINES BRIEFING
Whose documentation counts? Ancillary staff (e.g., RN, LPN, CNA) can document ROS, PFSH, and vital signs. These
three areas must be reviewed by the physician or non-physician practitioner (NPP) who must write a statement
that it is reviewed and correct or add to it. Only the physician or NPP that is conducting the E/M service can
perform the history of present illness (HPI). This is considered physician work and not relegated to ancillary staff.
The exam and medical decision making are also considered physician work and not relegated to ancillary staff.
Same Day Admit & Discharge (99234-99236) – At least two separate, face to face encounters should be
documented on a same day admit and discharge. The totality of the documentation for the date of service will be
considered against the history, exam, and MDM criteria of 99234-99236. These are the base criteria for the codes,
3 of 3 must be met or exceeded to report a code:
99234- (4 elements of HPI, 2 review of systems, 1 element of PFSH.) 2 elements of physical exam. Medical decision
making that is straightforward or low.
99235- (4 elements of HPI, 10 ROS or properly utilized caveat, 3 elements of PFSH.) 8 elements of physical exam.
Medical decision making of moderate complexity.
99236 – (4 elements of HPI, 10 ROS or properly utilized caveat, 3 elements of PFSH.) 8 elements of physical exam.
Medical decision making of high complexity.
Outpatient (99241-99245) and Inpatient (99251-99255) Consultations- In order to qualify as a consultation, three
requirements must be met: 1) the request from another physician or appropriate source must be documented in
the patient’s medical record, the consulting physician’s opinion and any services that were ordered or performed
must be documented in the patient’s medical record, and a written report communicating these opinions and
services must be communicated to the requesting physician or other appropriate source. The documentation from
the consultation service will be considered against the history, exam, and MDM criteria of 99241-99245 and
99251-99255. These are the base criteria for the codes, 3 of 3 must be met or exceeded to report a code:
99241/99251 – (1 element of HPI), 1 exam element, straightforward medical decision making.
99242/99252 – (1 element of HPI, 1 ROS element), 2 elements of exam, straightforward medical decision making
99243/99253 – (4 elements of HPI, 2 ROS elements, 1 element of PFSH), 2 elements of exam, low complexity
medical decision making
99244/99254 – (4 elements of HPI, 10 ROS elements or properly utilized caveat, 3 elements of PFSH,) 8 elements
of exam, moderate complexity medical decision making
99245/99255 – (4 elements of HPI, 10 ROS elements or properly utilized caveat, 3 elements of PFSH), 8 elements
of exam, high complexity medical decision making
Critical care (99291-99292) - In order to report these codes, the total time spent providing critical care services to
a critically ill or critically injured patient must be documented in the patient’s medical record. If critical care
services are performed alongside a separately billable procedure, you must also document that the time claimed is
independent of time spent performing additional services, i.e. “I performed __ minutes of critical care time which
is does not include time spent in separately billable procedures.”
Prolonged Services (99354-99359) – These codes report when a prolonged service is provided beyond the usual
service in either the inpatient or outpatient setting. When reporting prolonged services, there must be definitive
documentation of the total time the provider/s have spent with a patient on that DOS in order to tell if the time
spent exceeds the time included in the description of the primary E/M code. There is a time component for the
majority of E/M codes, for example, 99233 indicates that 35 minutes are typically spent performing this service. In
order to report prolonged services in addition to 99233 – in this example 99356, +99357 – we’d need to know that
at least 65 minutes was spent with the patient. This is because prolonged service of less than 30 minutes total
duration is not separately reportable.
Multiple DOS Inpatient Stay: Separate and distinct documentation is necessary for each E/M or DOS reported.
Initial Inpatient Admission (99221-99223) - The totality of the documentation for the first date of service in a
multi-day stay will be considered against the history, exam, and MDM criteria of 99221-99223. These are the base
criteria for the codes, 3 of 3 must be met or exceeded to report a code:
99221 – (4 elements of HPI, 2 ROS, 1 element of PFSH.) 2 elements of physical exam. Medical decision making that
is straightforward or low.
99222 – (4 elements of HPI, 10 ROS or properly utilized caveat, 3 elements of PFSH.) 8 elements of physical exam.
Medical decision making of moderate complexity.
99223 – (4 elements of HPI, 10 ROS or properly utilized caveat, 3 elements of PFSH), 8 elements of physical exam.
Medical decision making of high complexity.
Subsequent Inpatient Hospital Care (99231-99233) - The totality of the documentation for each subsequent date
of service in a multi-day stay will be considered against the history, exam, and MDM criteria of 99231-99233.
These are the base criteria for the codes, 2 of 3 must be met or exceeded to report a code:
99231 – (1 element of interval HPI), 1 exam element. Medical decision making that is straightforward or low
complexity.
99232 – (1 element of interval HPI, 1 interval ROS element), 2 elements of physical exam,. Medical decision making
of moderate complexity.
99233 – (4+ elements of interval HPI, 2 interval ROS elements, review of PFSH element), 2 elements of physical
exam. Medical decision making of high complexity.
Inpatient Discharge Services (99238-99239) - There must be definitive documentation of a face to face service to
report 99238-99239. Additionally, to qualify for 99239, more than 30 minutes of time spent performing the
discharge service must be documented. If less than 30 minutes are documented, or if the time is not documented,
only 99238 can be reported.
Multiple DOS Observation Stay: Separate and distinct documentation is necessary for each E/M or DOS
reported.
Initial Observation Care (99218-99220) - The totality of the documentation for the first date of service in a multiday stay will be considered against the history, exam, and MDM criteria of 99218-99220. These are the base
criteria for the codes, 3 of 3 must be met or exceeded to report a code:
99218 – (4 elements of HPI, 2 ROS, 1 element of PFSH.) 2 elements of physical exam. Medical decision making that
is straightforward or low.
99219 – (4 elements of HPI, 10 ROS or properly utilized caveat, 3 elements of PFSH.) 8 elements of physical exam.
Medical decision making of moderate complexity.
99220 – (4 elements of HPI, 10 ROS or properly utilized caveat, 3 elements of PFSH), 8 elements of physical exam.
Medical decision making of high complexity.
Subsequent Observation Care (99224-99226) - The totality of the documentation for each subsequent date of
service in a multi-day stay will be considered against the history, exam, and MDM criteria of 99224-99226. These
are the base criteria for the codes, 2 of 3 must be met or exceeded to report a code:
99224 – (1 element of interval HPI), 1 exam element. Medical decision making that is straightforward or low
complexity.
99225 – (1 element of interval HPI, 1 interval ROS element), 2 elements of physical exam. Medical decision making
of moderate complexity.
99226 - – (4+ elements of interval HPI, 2 interval ROS elements, review of PFSH element), 2 elements of physical
exam. Medical decision making of high complexity.
Observation Care Discharge Services (99217) – Observation care discharge of a patient from observation status
includes final exam* of the patient, discussion of the hospital stay, instructions for continuing care, and
preparation of discharge records. [* - There is no defined number of exam elements necessary to meet this
criteria, but an exam should still be done and documented]
Short Stay Summaries – If the patient is admitted and discharged on the same date of service, please see the
guidelines for “Same Day Admit and Discharge.” If the patient is admitted to observation for two dates of service,
please see the guidelines for “Multiple DOS Observation Stay.” If the patient is admitted to inpatient for two dates
of service, please see the guidelines for “Multiple DOS Inpatient Stay.” Separate and distinct documentation is
required for each DOS and/or E/M reported.
General Notes:
A properly utilized caveat for ROS is a statement from the provider that the elements have all been reviewed with
the patient and are negative or apart from the listed positives, otherwise negative. There are a number of
statements that would meet the criteria, so we just used "properly utilized caveat" for the sake of brevity.
This document is accurate, but not exhaustive. There are scenarios, such as additional time criteria for CMS, that
were left off in order to keep this a shorter, more manageable and useful document. These are the guidelines that
dictate the vast majority of encounters, however.