Inpatient Encounter Form

[Company Name]
Inpatient Encounter Form
[Date]

Patient Name Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Patient 6 Patient 7 Patient 8 Patient 9 Patient 10
Patient MRN Number 1111 1112 1113 1114 1115 1116 1117 1118 1119 1120
Patient Room Number 111 112 113 114 115 116 117 118 119 120
Patient Diagnosis xxx xxx xxx xxx xxx xxx xxx xxx xxx xxx
Service Service
Service
Category Code

Low Complexity MDM: 30 min. 99221

Admit

Mod. Complexity MDM: 50 min. 99222

High Complexity MDM: 70 min. 99223

Low Complexity MDM: 15 min. 99231

Follow-up
Visit

Mod. Complexity MDM: 25 min. 99232

High Complexity MDM: 35 min. 99233

Same Day

Low Complexity MDM 99234

Admit D/C

Mod. Complexity MDM 99235

High Complexity MDM 99236

Discharge Day Mgmt.: < 30 min 99238

D/C

Discharge Day Mgmt.: > 30 min. 99239

Prolong Critical

Constant Attention: 1st hour 99291

Care

Constant Attention: add'l 30 min. 99292

Dir. Prolonged Care: 1st hour 99356

Care

Dir. Prolonged Care: add'l 30 min. 99357

Prob. Focused Exam: 20 min. 99251

Consultation

Straightforward MDM: 40 min. 99252

Initial

Low Complexity MDM: 55 min. 99253

Mod. Complexity MDM: 80 min. 99254

High Complexity MDM: 110 min. 99255

Consultation

Low Complexity MDM: 10 min. 99261

Follow-up

Mod. Complexity MDM: 20 min. 99262

High Complexity MDM: 30 min. 99263

Low MDM Subsequent care: 15 min. 99311

Mod. MDM Subsequent care: 25 min. 99312

New or Established

High MDM Subsequent care: 35 min. 99313

Patient

Discharge Day Mgmt.: < 30 min. 99315

Discharge Day Mgmt.: > 30 min. 99316

Low MDM Annual Assessment: 30 min. 99301

Mod. MDM Annual Assessment: 40 min. 99302

High MDM Annual Assessment: 50 min. 99303

Discharge: 23 hours 99217

Observation

Low Complexity MDM: 23 hours 99218

Mod. Complexity MDM: 23 hours 99219

High Complexity MDM: 23 hours 99220