E/M CODE: ASSESSMENT CODES
📋 E/M Codes for Inpatient Assessment (Hospital Care)
| Service | Code | Key Elements | Typical Time |
|---|---|---|---|
| Initial Hospital Care (Admit) | 99221 | Detailed/Comprehensive History & Exam + Straightforward/Low MDM | 30 minutes |
| 99222 | Comprehensive History & Exam + Moderate MDM | 50 minutes | |
| 99223 | Comprehensive History & Exam + High MDM | 70 minutes | |
| Subsequent Hospital Care (Follow-up) | 99231 | Problem-focused History & Exam + Straightforward/Low MDM | 15 minutes |
| 99232 | Expanded problem-focused History & Exam + Moderate MDM | 25 minutes | |
| 99233 | Detailed History & Exam + High MDM | 35 minutes | |
| Hospital Discharge | 99238 | Discharge, 30 minutes or less | ≤30 minutes |
| 99239 | Discharge, more than 30 minutes | >30 minutes | |
| Observation Care (Admit/Discharge Same Day) | 99234 | Straightforward/Low MDM | 40 minutes |
| 99235 | Moderate MDM | 50 minutes | |
| 99236 | High MDM | 55 minutes |
✅ If the visit is an initial evaluation (first time seeing the patient) → use 99221–99223.
✅ If it’s daily rounding/follow-up → use 99231–99233.
✅ If you're discharging the patient → use 99238 or 99239 depending on time spent.