Documentation Guides

CPT Code Documentation Guides

Complete documentation guides for 15+ 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

Established patient office visit with low level of medical decision making.

4 requirements•15-20 minutes
CPT 992141.92 work RVU

Office Visit Level 4

Established patient office visit with moderate level of medical decision making.

4 requirements•25-30 minutes
CPT 992152.80 work RVU

Office Visit Level 5

Established patient office visit with high level of medical decision making.

4 requirements•40+ minutes
CPT 992031.60 work RVU

New Patient Level 3

New patient office visit with low level of medical decision making.

3 requirements•30 minutes
CPT 992042.60 work RVU

New Patient Level 4

New patient office visit with moderate level of medical decision making.

3 requirements•45 minutes
CPT 992053.50 work RVU

New Patient Level 5

New patient office visit with high level of medical decision making.

3 requirements•60+ minutes
CPT 992233.86 work RVU

Hospital Admission Level 3

Initial hospital admission with comprehensive evaluation.

4 requirements•60+ minutes
CPT 992321.39 work RVU

Hospital Progress Note Level 2

Daily hospital visit with moderate complexity decision making.

4 requirements•25-35 minutes
CPT 992914.50 work RVU

Critical Care First Hour

Evaluation and management of critically ill patient, first 30-74 minutes.

4 requirements•30-74 minutes

Therapeutic Procedures

Treatment procedures and injections

CPT 206101.23 work RVU

Major Joint Injection

Aspiration and/or injection of a major joint (knee, shoulder, hip).

6 requirements•15 minutes

Preventive Services

Wellness visits and screenings

CPT 993951.50 work RVU

Annual Physical 18-39

Comprehensive preventive medicine evaluation for adults 18-39.

4 requirements•30 minutes
CPT 993961.75 work RVU

Annual Physical 40-64

Comprehensive preventive medicine evaluation for adults 40-64.

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

Initial AWV

Initial Medicare Annual Wellness Visit with personalized prevention plan.

5 requirements•45-60 minutes

Psychiatric Services

Mental health evaluations and therapy

CPT 908341.50 work RVU

Psychotherapy 45 min

Individual psychotherapy session, approximately 45 minutes.

4 requirements•45 minutes
CPT 907913.00 work RVU

Psych Eval

Comprehensive psychiatric diagnostic evaluation.

5 requirements•60-90 minutes

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.