Initial Hospital Visit: Coverage and Documentation Requirements

Published 02/15/2021

This electronic Comparative Billing Report (eCBR) focuses on providers who have submitted claims for Initial Hospital E/M Services CPT® Codes 99221–99223. eCBR 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 coverage guidelines.

For your personalized Initial Hospital E/M Services CPT® 99221–99223 eCBR results, log on to eServices portal. An eCBR should be available for providers who have at least 10 claims in history for this CPT code family during the time period selected.  

Overview of CPT Codes 99221–99223 Initial Hospital Care

Key components in documenting E/M CPT codes 99221–99223 are:

  • History
  • Examination
  • Medical Decision-Making

Description and Documentation Requirements for CPT Codes  99221-99223

CPT Code
Description
Key Components: all three components are required
99221
  • Typically 30 minutes
  • Usually problems are low severity
  • Detailed or comprehensive history
  • Detailed or comprehensive examination
  • Medical decision-making of straightforward or low complexity
99222
  • Typically 50 minutes
  • Usually problems are moderate severity
  • Comprehensive history
  • Comprehensive examination
  • Medical decision-making of moderate complexity
99223
  • Typically 70 minutes
  • Usually presenting problems are high severity
  • Comprehensive history
  • Comprehensive examination
  • Medical decision-making of high complexity

For more guidance on the key components listed above, review the CMS MLN Evaluation and Management Services guide listed in the resource section.

Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs.

Methods
The metrics reviewed in this eCBR are the proportion of billing for each CPT code in the E/M grouping with comparisons to peers within the nationwide Railroad Retirement Board Specialty Medicare Administrative Contractor (RRB SMAC) 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 claims for CPT codes 99221–99223 at levels compared to your peers in the RRB SMAC.

Example of eCBR Results from eServices


 
Please be aware that the information contained within this eCBR is not intended to be punitive or an indication of fraud. Rather, it is intended to be proactive communication that will assist you in identifying potential billing issues and help you with performing a self-audit of your conformity with Medicare guidelines.

For more information about this or other eCBRs, please call our Provider Contact Center at 888–355–9165 and select Option 5. Customer Service Representatives are available Monday through Friday, from 8:30 a.m. to 4:30 p.m. in all time zones except for Pacific Time, which receives service from 8:30 a.m. to 4 p.m. PT.

Educational Resources

CMS Resources

Palmetto GBA Railroad Medicare Resource: Evaluation and Management (EM) Help Center