The Evaluation and Management codes (99201 – 99499) are used by most physicians in
reporting a significant portion of their services and are divided into broad categories such as office visits, hospital visits, new patient encounters and consultations. Most of these categories are further divided into two or more subcategories of E/M services. For example, there are two subcategories of office visits (new patient and established patient) and there are two subcategories of hospital visits (initial and subsequent). To properly define the E/M services, there are seven components recognized: History, Examination, Medical Decision Making (MDM), Nature of the Presenting Problem (NPP),
Counseling, Coordination of Care, and Time. The first three components, History, Examination and Medical Decision Making are recognized as the key components of E/M services. Each of the three key components is further divided into four categories. The History includes: CC, HPI, PFSH and ROS. The four levels of the Physical Examination are: Problem Focused, Expanded Problem Focused, Detailed and Comprehensive. The four elements of Medical Decision Making include: Straight
Forward, Low Complexity, Moderate Complexity and High Complexity. By year end, it is the intent for this part of the AHS website to have thoroughly reviewed the CPT (and ICD) coding system as it applies to the care of the headache patient.
To a large extent physicians use about four or five different types of service codes for the majority of care they provide. The most frequently used outpatient visit CPT codes are:
Initial visits: CPT codes 99201 – 99205
Established patient visits: CPT codes 99211 – 99215
Office consultations, new or established patients: CPT codes 99241 – 99245
The most commonly used hospital care codes are:
Initial hospital care: CPT codes 99221 – 99223
Subsequent hospital care: CPT codes 99231 – 99233
Inpatient consultations, new or established patients: CPT codes 99251 – 99255
