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Documentation of Level of Service

of Medical Encounters

Created by The Lung Doctor for e-Medtools


Inpatient Encounters
Initial Hospital Encounter Subsequent Inpatient
Or Observation Or Follow up
Requires 3 components within shaded area Requires 2 components
History D or C C C PF EPF D
Examination D or C C C PF EPF D
Complexity of SF/L M H SF/L M H
medical decision
LEVEL I II III I II III
Init Hosp Care
99221 99222 99223 99231 99232 99233
Observation 99261 99262 99263
99218 99219 99220

C = Complete D = Detailed EPF = Extended problem focused H = High M = Moderate PF = Problem focused SF/L = Straight forward/Low
C = Complete D = Detailed EPF = Extended problem focused H = High M = Moderate PF = Problem focused SF/L = Straight forward/Low

Adaptedfrom
fromCMS
CMSMedicare
MedicarePart
PartBB HGSAdministrators
HGSAdministratorsDocumentation
DocumentationWorksheet
Worksheet
Adapted

Created by The Lung Doctor for e-Medtools


Outpatient,
Consults (Outpatient, Inpatient) and ER
New Office / Consult / ER Established Office
Requires 3 components within shaded area Requires 2 components
History PF EPF D C C Minimal PF EPF D C
problem
ER: PF ER: EPF ER: EPF ER: D ER: C that may
not
Examination PF EPF D C C require PF EPF D C
ER: PF ER: EPF ER: EPF ER: D ER: C presence
of
Complexity SF SF L M H physician SF L M H
of medical ER: SF ER: L ER: M ER: M ER: H
decision
LEVEL I II III IV V I II III IV V
New Pt 99-201 -202 -203 -204 -205 99211 -212 -213 -214 -215
Outpt Consult 99-241 -242 -243 -244 -245
Inpt Consult 99-251 -252 -253 -254 -255
ER 99-281 --282 -283 -284 -285
Adaptedfrom
fromCMS
CMSMedicare
MedicarePart
PartBB HGSAdministrators
HGSAdministratorsDocumentation
DocumentationWorksheet
Worksheet
Adapted

Created by The Lung Doctor for e-Medtools


Documenting Time
As a Determinant of Level of Service
“If the physician documents total time and suggests that counseling or coordinating care dominates (more than 50%)
the encounter, time may determine level of service. Documentation may refer to: prognosis, differential diagnosis,
risks, benefits of treatment, instructions, compliance, risk reduction or discussion with another health care provider.”

Does documentation reveal total time?


Time: Face to face in outpatient setting
□Yes □No
Unit/floor in inpatient setting
Does documentation describe the content of
counseling or coordinating care □Yes □No

Does documentation reveal that more than half


the time was counseling or coordinating care? □Yes □No

Documentation of Time requires that ALL of the answers to the above questions are YES
Adaptedfrom
fromCMS
CMSMedicare
MedicarePart
PartBB HGSAdministrators
HGSAdministratorsDocumentation
DocumentationWorksheet
Worksheet
Adapted

Created by The Lung Doctor for e-Medtools

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