This page addresses follow-up questions and additional information pertinent to our webinar Making the Rounds: Inpatient E/M Coding.
** The coding information and guidance are valid at the time of publishing. Learners are encouraged to research
subsequent official guidance in the areas associated with the topic as they can change rapidly.

Q:  How is a unique test defined for medical decision-making amount and/or complexity of data to be reviewed and assessed credit?
A:  A unique test is defined by the CPT code. When multiple results of the same unique test are reviewed during an encounter, credit for one unique test is counted.

Q:  Regarding risk of complications and/or morbidity or mortality, if a procedure is indicated, does a provider need to specify within the documentation whether the procedure is a “minor surgery” or “major surgery” to differentiate between the two surgery classifications?
A:  Yes, best practice is for the provider to document whether the procedure is considered a major or minor surgery. The classification is based on the common meaning as determined by the trained clinician. These terms are not defined by the CPT global package definition of a minor or major surgery. Risk for any procedure is dependent on specific patient-risk factors as determined by the provider.

Q:  When time is documented, but the MDM documentation reflects a higher level of service, may the level of service be determined by the MDM documentation instead of time?
A:  Appropriate level selection should be based on the patient encounter and relevant elements. Leveling an encounter on MDM may be more appropriate on cases with higher complexity and cognitive load. Leveling on time may more accurately capture the work performed when the work is time intensive on the date service.

Q: We need recommendations on Hospitalist coding for inpatient visits. We are specialty group and Hospitalist also falls under same specialty. How do we bill hospitalist visit on the day of surgery, is it initial care or subsequent care?

H&P is performed on the day of surgery by attending provider and we don’t bill his/her services as they fall under global package. Would it be correct if we bill Hospitalist initial day 1 visit with subsequent visit code?

Hospitalist hospital care:
They are not to bill 99221 – 99223…initial visit.
They are to bill 99231 – 99233…subsequent visit.

A: The 2023 AMA CPT E/M guidelines define an initial service as below:

 An initial service is when the patient has not received any professional services from the physician or other qualified health care professional or another physician or other qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, during the inpatient, observation, or nursing facility admission and stay.”

If the hospitalist meets that definition, then they could bill an initial hospital service code the first time they see the patient.  Please check your payors and your Medicare administrative contractor’s reimbursement policies.

1/25/23: BREAKING NEWS: There were some recent updates regarding inpatient/observation care services that relate to inpatient E/M coding.

The 2023 AMA CPT code set brought us many revisions to the E/M guidelines. The good news is that we get to use the same set of guidelines for all E/M services!  One of the more significant changes was to the inpatient and observation services codes.  The observation services codes (99217-99226) were deleted and the code descriptors for inpatient services (99221-99233) were revised to include observation services. This caused us to question what reporting observation services would look like for Medicare. Until recently we had not seen any updates from Medicare on how to process observation services, however, they have now offered some guidance:

  • Observation care codes are billed only by the admitting physician
  • All other practitioners providing care to patients receiving observation services bill office and other outpatient visits, codes 99202-99205 or 99211-99215
  • New vs. established patient rules apply
  • Modifier AI is not appending to initial observation care services
  • All observation services claims should be reported with place of service code 22 (POS 22)


Looking for additional information on this topic?

Deanna Upston, CPMA, CPC, COSC

Deanna Upston, CPMA, CPC, COSC


Deanna is a consultant for The Haugen Consulting Group with over 20 years of health care industry experience.  Her introduction was through medical assisting, which she enjoyed for several years. Once she was established at a surgeon’s office, she started coding their surgical cases and discovered that was her favorite part of the day. Deanna has experience working on the professional fee side of coding, audit, education and compliance serving coders and physicians.  She has put together multiple education sessions for both provider and coder.  She also has experience working as an analyst in which she validated the integrity of editing logic during the implementation of claim scrubbing software.


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