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Evaluation Management Codes - American Psychiatric …

294 Codes and Documentation for Evaluation and Management ServicesThe Evaluation and Management (E/M) Codes were introduced in the 1992 up-date to the fourth edition of Physicians Current Procedural Terminology (CPT).These Codes cover a broad range of services for patients in both inpatient andoutpatient settings. In 1995 and again in 1997, the Health Care Financing Ad-ministration (now the Centers for Medicare and Medicaid Services, or CMS)published documentation guidelines to support the selection of appropriateE/M Codes for services provided to Medicare beneficiaries. The major differ-ence between the two sets of guidelines is that the 1997 set includes a single-sys-tem psychiatry examination (mental status examination) that can be fullysubstituted for the comprehensive , multisystem physical examination requiredby the 1995 guideline.

99221 —Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components: • A detailed or comprehensive history • A detailed or comprehensive examination • Medical decision making that is …

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