Different coding documentation requirements can seem convoluted. This resource details coding documentation requirements and gives you nephrology specific examples and codes.

Chief Complaint

  • Chief Complaint is a concise statement describing the symptom, problem, condition or other factor that is the reason for the encounter
  • The medical Record should always clearly reflect the chief complaint

Chief Complaint

E/M codes that have levels of services include a medically appropriate history and/or physical examination, when performed. The nature and extent of the history and/or physical examination are determined by the treating physician or other qualified health care professional reporting the service. The care team may collect information, and the patient or caregiver may supply information directly (eg, by electronic health record [EHR] portal or questionnaire) that is reviewed by the reporting physician or other qualified health care professional. The extent of history and physical examination is not an element in selection of the level of these E/M service codes.

Examination Elements

  • Constitutional
  • Eyes
  • Ears, Nose, Mouth & Throat
  • Cardiovascular
  • Respiratory
  • Gastrointestinal
  • Genitourinary
  • Musculoskeletal
  • Skin
  • Neurological
  • Psychiatric
  • Hematologic/lymphatic /immunologic

Examination Levels
To qualify for a given level of examination, the following content and documentation requirements must be met:

Examination Level Documentation must include Examination of
Problem Focused Exam 1 body area or system
(relevant affected area)
Expanded Problem Focused Exam 2-4 body areas or systems
(including affected area)
Detailed Exam 5-7 body areas or systems
(including affected area)
Comprehensive Exam 8 or more body areas or systems

Medical Decision Making

MDM refers to the complexity of establishing a diagnosis and/or selecting management option as measured by the following:

  • Number and Complexity of Problems Addressed at the Encounter.
  • Amount and/or Complexity of Data to be Reviewed and Analyzed.
  • Risk of Complications and/or Morbidity or Mortality of Patient Management.

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Observation Hospital Visits

The Admitting physician

is the only provider who bills Observation Codes.

If an ESRD patient Observation visits count towards MCP

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Time Based Visit – Office/Outpatient

Time – definition is revised for 2021:

  • Time is cumulative on the date of service
    • Face-to-face by physician and other qualified healthcare professional
      • Ancillary staff time doesn’t count
  • Time includes non-face-to-face services
    • Preparing to see the patient (e.g., review of tests)
    • Obtaining and/or reviewing separately obtained history
  • Time no longer requires:
    • Counseling and/or coordinating of care
    • > than 50% of time
  •  Total time must be documented – no start or stop time is required
Code Description CPT Level

(table on page 2)

Time (minutes)
Office or other outpatient visit for the evaluation and management of a NEW patient which requires medically appropriate history and/or examination and [SF/Low/Mod/High] level of medical decision making. 99202 Straightforward 15 -29
99203 Low 30 – 44
99204 Moderate 45 – 59
99205 High 60 – 74
Office or other outpatient visit for the evaluation and management of an ESTABLISHED patient which requires medically appropriate history and/or examination and [SF/Low/Mod/High] level of medical decision making. 99211* N/A N/A
99212 Straightforward 10 – 19
99213 Low 20 – 29
99214 Moderate 30 – 39
99215 High 40 – 54

Time Based Visit

Time can be a component:

  • For visits in which counseling and/or coordination of care by a provider is greater than 50% of the time spent with the patient and/or family
  • Medical record – total time and time spent in face to face counseling or coordination of care.
Initial Hospital Visit Subsequent Hospital Visit
40 minutes met or exceeded
25 minutes met or exceeded
55 minutes met or exceeded
35 minutes met or exceeded
75 minutes met or exceeded
50 minutes met or exceeded

Inpatient/Outpatient Dialysis Service

  • 90935: Single Evaluation of Hemodialysis Procedure by a physician or other qualified healthcare professional
  • 90937: Hemodialysis procedure requiring repeated evaluation(s) with or without substantial revision of dialysis prescription (use this when patient has an adverse event during dialysis)

Comprehensive Assessment Documentation

  • Comprehensive assessment should be performed at least once per month and include:
    • Patient’s current status and complaints
    • Physical exam
    • Assessment of adequacy of ESRD treatment including dialysis
    • Status of vascular access
    • Assessment and treatment of other conditions associated with ESRD (e.g., anemia, electrolyte management and bone density)
    • Plan of treatment and any changes to the patient’s management

Monthly Capitation Payment Excluded Services

Excluded Services:

  • Comprehensive evaluation for transplant
  • Evaluation of potential living donor
  • Self-dialysis training
  • Non-renal related physician visits
  • Hospital inpatient services
  • Physician services that initiate outpatient dialysis

At NPS, we are committed to providing resources and solutions that deliver economic growth, practice stability and operational efficiencies to our physician partners. NPS offers coding review services to help guide your practice in accurate coding. Click here to learn more about our coding review or feel free to email or call us to speak directly to a member of the NPS team.

This guide is provided for informational purposes only, not as advice for your specific practice, and it should not be solely relied upon for appropriate coding.