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Documentation Guides

CPT Code Documentation Guides

Complete documentation guides for 34+ medical procedures. Learn requirements, billing tips, and how Scribeable automates compliance.

Evaluation & Management

Office visits, consultations, and hospital services

CPT 992131.30 work RVU

Office Visit Level 3

3 requirements•15-20 minutes
CPT 992141.92 work RVU

Office Visit Level 4

3 requirements•25-30 minutes
CPT 992152.80 work RVU

Office Visit Level 5

3 requirements•40+ minutes
CPT 992031.60 work RVU

New Patient Level 3

2 requirements•30 minutes
CPT 992042.60 work RVU

New Patient Level 4

2 requirements•45 minutes
CPT 992053.50 work RVU

New Patient Level 5

2 requirements•60+ minutes
CPT 992233.86 work RVU

Hospital Admission Level 3

4 requirements•60+ minutes
CPT 992321.39 work RVU

Hospital Progress Note Level 2

4 requirements•25-35 minutes
CPT 992914.50 work RVU

Critical Care First Hour

4 requirements•30-74 minutes
CPT 992110.18 work RVU

Office Visit Level 1

4 requirements•5 minutes
CPT 992821.42 work RVU

ED Visit Level 2

4 requirements•15-20 minutes
CPT 992832.56 work RVU

ED Visit Level 3

5 requirements•20-30 minutes
CPT 992843.82 work RVU

ED Visit Level 4

6 requirements•30-45 minutes
CPT 992855.00 work RVU

ED Visit Level 5

6 requirements•45-60 minutes
CPT 992332.00 work RVU

Hospital Follow-Up Level 3

5 requirements•35-40 minutes
CPT 994900.61 work RVU

CCM

5 requirements•20+ minutes/month
CPT 994570.50 work RVU

RPM

5 requirements•20+ minutes/month
CPT 994971.50 work RVU

Advance Care Planning

6 requirements•30 minutes

Surgical Procedures

Operative and procedural interventions

CPT 111020.55 work RVU

Skin Biopsy

7 requirements•10-15 minutes
CPT 2744720.72 work RVU

Total Knee Replacement

8 requirements•60-120 minutes

Diagnostic Procedures

Tests and examinations for diagnosis

CPT 453783.69 work RVU

Colonoscopy

7 requirements•30-45 minutes
CPT 453804.43 work RVU

Colonoscopy w/ Biopsy

6 requirements•30-50 minutes
CPT 432393.25 work RVU

EGD with Biopsy

8 requirements•20-30 minutes
CPT 930000.29 work RVU

EKG

7 requirements•5-10 minutes

Therapeutic Procedures

Treatment procedures and injections

CPT 206101.23 work RVU

Major Joint Injection

6 requirements•15 minutes
CPT 170000.46 work RVU

Cryotherapy

5 requirements•5-15 minutes
CPT 644831.90 work RVU

Epidural Injection

7 requirements•20-30 minutes

Preventive Services

Wellness visits and screenings

CPT 993951.50 work RVU

Annual Physical 18-39

4 requirements•30 minutes
CPT 993961.75 work RVU

Annual Physical 40-64

4 requirements•30-40 minutes
CPT G04382.43 work RVU

Initial AWV

5 requirements•45-60 minutes
CPT G04391.50 work RVU

Subsequent AWV

5 requirements•30-40 minutes

Psychiatric Services

Mental health evaluations and therapy

CPT 908341.50 work RVU

Psychotherapy 45 min

4 requirements•45 minutes
CPT 907913.00 work RVU

Psych Eval

5 requirements•60-90 minutes
CPT 961270.14 work RVU

Behavioral Screen

5 requirements•5-10 minutes per instrument

Automate Documentation Compliance

Scribeable automatically captures required documentation elements for proper CPT coding, reducing denials and maximizing reimbursement.

CPT Code Documentation Guides

Complete documentation guides for medical procedures and CPT codes. Learn billing requirements, documentation tips, and best practices.

Evaluation & Management

Office visits, consultations, and hospital services

  • CPT 99213: Office Visit Level 3

  • CPT 99214: Office Visit Level 4

  • CPT 99215: Office Visit Level 5

  • CPT 99203: New Patient Level 3

  • CPT 99204: New Patient Level 4

  • CPT 99205: New Patient Level 5

  • CPT 99223: Hospital Admission Level 3

  • CPT 99232: Hospital Progress Note Level 2

  • CPT 99291: Critical Care First Hour

  • CPT 99211: Office Visit Level 1

  • CPT 99282: ED Visit Level 2

  • CPT 99283: ED Visit Level 3

  • CPT 99284: ED Visit Level 4

  • CPT 99285: ED Visit Level 5

  • CPT 99233: Hospital Follow-Up Level 3

  • CPT 99490: CCM

  • CPT 99457: RPM

  • CPT 99497: Advance Care Planning

Surgical Procedures

Operative and procedural interventions

  • CPT 11102: Skin Biopsy

  • CPT 27447: Total Knee Replacement

Diagnostic Procedures

Tests and examinations for diagnosis

  • CPT 45378: Colonoscopy

  • CPT 45380: Colonoscopy w/ Biopsy

  • CPT 43239: EGD with Biopsy

  • CPT 93000: EKG

Therapeutic Procedures

Treatment procedures and injections

  • CPT 20610: Major Joint Injection

  • CPT 17000: Cryotherapy

  • CPT 64483: Epidural Injection

Preventive Services

Wellness visits and screenings

  • CPT 99395: Annual Physical 18-39

  • CPT 99396: Annual Physical 40-64

  • CPT G0438: Initial AWV

  • CPT G0439: Subsequent AWV

Psychiatric Services

Mental health evaluations and therapy

  • CPT 90834: Psychotherapy 45 min

  • CPT 90791: Psych Eval

  • CPT 96127: Behavioral Screen