The format for this article and case studies were provided by Yong S. Han, MD, FAAP, and members of the American Academy of Pediatrics (AAP) Section on Hospital Medicine Subcommittee on Billing & Coding.

The hospital evaluation and management (E/M) category of services can be differentiated by the place of service (observation or inpatient hospital) and type of service (ie, initial and subsequent services; consultations and discharge services). All hospital E/M services are global—they include all E/M services provided by the same physician (or physician of the same specialty within a group) during a calendar day. Any procedures performed on the same day of service should be reported separately. These services may be performed and reported by any physician of any specialty (eg, hospitalist, primary care physician, pulmonologist).

Current Procedural Terminology (CPT®) includes 2 categories of hospital E/M codes (excluding consultations). There is no distinction between new and established patients....

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