99223 CPT Code (2023) | Description, Guidelines, Reimbursement, Modifiers & Examples
99223 CPT code is defined as three essential components of Initial hospital therapy each day: a complete history, a thorough examination, and high-complexity medical decision-making for the patient.
Depending on the severity of the problem(s) and the needs of the patient and family, we provide counseling and treatment coordination with other clinicians or organizations.
Most of the time, the issues that need hospitalization are of the most severe kind.
When a doctor examines a patient in the emergency and decides to admit them to a hospital, emergency room carriers pay for the first hospital treatment or patient counseling.
Doctors spend 70 minutes with the patient and the unit where the patient is being treated at the patient’s bedside.
99223 CPT Code | Description
When a patient is admitted to the hospital, it is usually because their health has deteriorated.
The average time spent at the nurse’s station and on the patient’s ward or floor is 70 minutes per patient daily.
Consultations with other physicians, professional healthcare providers, or organizations may be given as required based on the severity of the condition and patient and family needs.
Medical necessity is the primary criterion for Medicare reimbursement.
Therefore, documentation for the E/M CPT code’s necessary components is also required.
However, a patient’s condition at the time of the appointment may only be considered for evaluating the quality of treatment, not the quantity of paperwork.
After this session, a detailed medical and surgical history and a thorough assessment of all systems must be collected.
Another option is to use a single-system test, such as a cardiac or respiratory exam, or a multi-system exam, to complete the whole diagnostic procedure in certain circumstances.
Suppose medical records reveal that the work and medical necessity conditions for reporting a later hospital code under the level selected have been met.
In that case, a later hospital care 99223 cpt code is more appropriate for reporting. During the patient’s hospitalization, this number denotes the provider’s first E/M service.
CERT (Recent Comprehensive Error Rate Testing) errors are closely monitored to determine which ones are the most responsible for the high error rate in our jurisdiction.
CPT is the most generally used medical terminology.
Errors found by WPS Government Health Administrators or other CMS-affiliated contractors may be sent to providers for further evaluation and education.
When invoicing for primary care and discharge management services simultaneously, carriers must inform doctors that doing so is not permissible.
It is conceivable that a doctor will determine that a patient’s account should be charged for both the hospital discharge management code and an initial care code if the patient is discharged and hospitalized on separate days.
99223 CPT Code | Billing Guidelines
99223 CPT code denotes the highest degree of initial care for patients admitted to the hospital.
This level of treatment was selected by 67.73 percent of admission H&P contacts in 2018, making it the most frequently used code for billing purposes.
Medicare has authorized a payment of $206 for this treatment, which is equivalent to 3.86 RVUs.
Once a day, this code may be billed only be used once. As a rule, the topics presented are severe.
Patient evaluation and management begin when they are admitted as an inpatient by a doctor.
Important guidelines are given below:
Suppose a doctor concludes that a patient needs hospitalization after evaluating them in an emergency department.
In that case, insurance companies will pay the cost of the first hospital care service or the first inpatient consultation for that patient.
This E/M service is provided at no cost to the customer.
It is not covered under the plan’s benefits for a single visit to the emergency room by the same doctor on the same day.
An individual who visits the hospital via another service, such as their doctor’s office or the emergency department, rather than through the emergency room itself is considered to have gotten all of the care they need from a physician on the same day.
Same-day admission and release from the hospital.
Patients are not required to pay a hospital discharge management code at admission.
Carriers only pay for the first hospital care code. If a physician wants to claim both initial hospital treatments, they should be informed that they cannot.
If the discharge and admission occur on different days, the post-discharge management and the original hospital care codes may be used to bill the hospital.
They were relocating to another facility within the same complex; or moving from one department to another inside the same institution.
How To Use Modifiers With CPT code 99223
The Modifiers are two-digit representations used with a service or procedure code, for example, 99223 CPT code – 99225, during claim submission to alert payors that the service or treatment was delivered in a unique circumstance.
For example, the modifier of the 99223 CPT code is “-25”. The doctor gave many personalized evaluation and management services (i.e., “-25”).
Additional evaluation and management services may be required for patients whose circumstances need it.
“-25” might also represent the quantity of evaluation and management services necessary to perform the medication or service when a CPT-4 code was issued.
“-25” is the modifier of the 99223 CPT CODE
Reimbursement Explained
It is required that physicians working in the same group be compensated as though they were all practicing in the same specialty.
On the other hand, patients who get face-to-face tests and treatment services for two wholly unrelated ailments will not be able to be tracked down.
Therefore, clinicians should determine a service level corresponding to the total number of appointments instead of charging per appointment for billing reasons.
Visits are described as “per day,” which indicates that the patient will be attended to throughout the day.
The phrase “per day” underlines that the code and payment associated with an inpatient hospital stay reflect all services rendered on that particular day.
The physician should choose the most appropriate service code on the day of service.
It is appropriate to reimburse doctors for their visits as long as each is responsible for a distinct component of the patient’s treatment and the visits are billed under various diagnoses.
The payment of a second physician’s visit by a contractor covering for a patient who has previously visited the doctor is prohibited under federal law.
Initial Hospital Care Payments: 99221 – CPT Code 99223
After more than 50 years, the American Medical Association (AMA) has agreed on a standard system for assigning and maintaining code sets that accurately reflect current clinical practice and medical innovation.
Initial Hospital Care From Emergency Room Carriers: Pay for initial hospital care or initial inpatient counselling when a doctor examines their patient in the emergency room and determines to admit the person to the hospital.
You don’t pay for both E / M services.
Plus, you don’t pay for an emergency room visit from the initial doctor on the same date of service.
If the patient is admitted to the hospital through a different place of operation.
For example, the same date of admission.
Initial Hospital Care on Day Following Visit Carriers: Pay for both visits if a patient is examined in practice one day and hospitalised the day after, even if less than two hours have expired between the admission and the visit.
Initial Hospital Care and Discharge on Same Day Carriers: Only pay the hospital first aid code if a patient is admitted and discharged on the same day.
You do not send payment to the hospital discharge management code on the day of admission.
Carriers must inform the physicians not to simultaneously bill a hospital primary care code and discharge management code.
Physicians can charge both the hospital discharge management code and an initial care code if discharge and admission are not the same day if the transfer is between:
- Various hospitals
- Multiple jointly owned entities that do not have consolidated records
- Between the acute care hospital and a PPS exempt department within the same hospital if there are no combined records
- Medical services including transfer from one hospital to another
- On-site transfer to a future payment system
- Hospital Released Department
- Transfer of a facility to another separate entity under the same ownership or part of the same complex
- Transfer from one department to another within a single facility
Billing Examples
The following are examples of when CPT code 99223 may be used.
Example 1
A 25-year-old quadriplegic patient who was just admitted to the rehabilitation unit for the first time was admitted to the hospital for the first time.
The discipline of medicine known as Physical Medicine and Rehabilitation (PM&R) focuses on caring for patients with various physical impairments.
Example 2
To begin therapy, a 58-year-old patient was taken to the hospital with acute chest pain, which was previously unrecognized. (Cardiology)
Example 3
The patient’s family situation is problematic, and he was expelled from school following a baseball bat attack on a teacher.
An uncooperative/resistant young kid who is sad and abusing many substances is his first encounter with the medical staff at the hospital.
Example 4
The patient has a significant arthritic flare, new mouth ulcers, gastrointestinal pain, and leucopenia when they first come.
Therefore, methotrexate, corticosteroids, and non-steroidal anti-inflammatory medicines are prescribed to treat a lady with anatomical stage 3, ARA functioning class 3, and RA.
Example 5
The parents of a continuously suicidal teenager have sought an initial hospital visit because they are concerned about being separated from their daughter (Psychiatry).
Example 6
On examination, a significant recurrence of the glottis with a mass in the neck is discovered in a 45-year-old woman who has been suffering from deteriorating stridor and dysphagia and has previously been treated with radiation therapy for laryngeal cancer.
Example 7
On with the medical center for an older teenage kid who has been acting suicidal for the last six months and has a history of running away from home after physical altercations with his father.
Example 8
Inpatient treatment for a 16-year-old boy who was depressed and sullen with a six-month history of poor academic performance, increasing self-endangerment, and resistance to parental expectations.
Example 9
The patient’s initial hospitalization is marked by an acute flare-up of her arthritis and new mouth ulcers, stomach discomfort, and a white blood cell count drop.
He takes methotrexate, corticosteroid, and nonsteroidal anti-inflammatory medicines to control her symptoms.
Example 10
First-time partial hospitalization was required for a 16-year-old kid who had become sad, had a six-month history of self-injury, and had refused to succumb to family pressure.
Example 11
Initial hospital visit for a 45-year-old female, who has a history of rheumatic fever as a child and now has anemia, fever, and congestive heart failure. (Cardiology)
Example 12
Initial hospital visit for a 50-year-old male with acute chest pain and diagnostic electrocardiographic changes of an acute anterior myocardial infarction. (Cardiology/Family Medicine/Internal medicine)
Example 13
Initial hospital visit for a 75-year-old with progressive stridor and dysphagia with history of cancer of the larynx treated by radiation therapy in the past.
Exam shows a large recurrent tumour of the glottis with a mass in the neck. (Otolaryngology/Head & Neck Surgery)
Example 14
Initial hospital visit for a 70-year-old male admitted with chest pain, complete heat block, and congestive heart failure. (Cardiology)
Example 15
Initial hospital visit for an 82-year-old male who presents with syncope, chest pain, and ventricular arrhythmias. (Cardiology)
Example 16
Initial hospital visit for a 75-year-old male with history of arteriosclerotic coronary vascular disease, who is severely dehydrated, disoriented, and experiencing auditory hallucinations, (Psychiatry)
Example 17
Initial hospital visit for a 70-year-old male with alcohol and sedative-hypnotic dependence, admitted by family for severe withdrawal, hypertension, and diabetes mellitus. (Psychiatry)
Example 18
Initial hospital visit for a persistently suicidal latency-aged child whose parents have requested admission to provide safety during evaluation but are anxious about separation from her. (Psychiatry)
Example 19
Initial psychiatric visit for an adolescent patient without previous psychiatric history, who was transferred from the medical ICU after a significant overdose. (Psychiatry)
Example 20
Initial hospital visit for a 35-year-old female with severe systemic lupus erythematosus on corticosteroid and cyclophosphamide, with new onset of fever, chills, rash, and chest pain. (Rheumatology)
Example 21
Initial hospital visit for a 52-year-old male with know rheumatic heart disease who presents with anasarca, hypertension, and history of alcohol abuse. (Cardiology)
Example 22
Initial hospital visit for a 55-year-old female with a history of congenital heart disease; now presents with cyanosis. (Cardiology)
Example 23
Initial hospital visit for a psychotic, hostile, violently combative adolescent, involuntarily committed, for seclusion and restraint in order to provide for safety on unit. (Psychiatry)
Example 24
Initial hospital visit for a now subdued and sullen teenage male with six-month history of declining school performance, increasing self-endangerment, and resistance of parental expectation, Including running away past weekend after physical fight with father. (Psychiatry)
Example 25
Initial partial hospital admission for a 17-year-old female with history of borderline mental retardation who has developed auditory hallucinations.
Parents are know to abuse alcohol, and Child Protective Service is investigating allegations of sexual of abuse of a younger sibling. (Psychiatry)
Example 26
Initial hospital visit of a 67-year-old male admitted with a large neck mass, dysphagia, and history of myocardial infarction three months before. (Otolaryngology/Head & Neck Surgery)
Example 27
Initial hospital visit for a patient with suspected cerebrospinal fluid rhinorrhea that developed two weeks after head injury. (Otolaryngology/Head & Neck Surgery)
Example 28
Initial hospital visit for a 25-year-old female with history of poly-substance abuse and psychiatric disorder, The patient appears to be psychotic with markedly elevated vital signs. (Psychiatry)
Example 29
Initial hospital visit for a 70-year-old male with cutaneous Y-cell Iymphoma who has developed fever and lumphadenopathy. (Internal Medicine)
Example 30
Initial hospital visit for a 62-year-old female with know coronary artery disease, for evaluation of increasing edema, dyspnea on exertion, confusion, and sudden onset of fever with productive cough. (Internal Medicine)
Example 31
Initial hospital visit for a 3-year-old female with 36-hour history of sore throat and high fever; now with sudden onset of lethargy, irritability, photophobia, and nuchal rigidity. (Pediatrics)
Example 32
Initial hospital visit for a 26-year-old female for evaluation of severe facial fractures (LeFort’s ll/lll) (Plastic Surgery)
Example 33
Initial hospital visit for a 55-year-old female for bilateral mandibular fractures resulting in flail mandible and airway obstruction. (Plastic Surgery)
Example 34
Initial hospital visit for a 71-year-old patient with a red painful eye four days following uncomplicated cataract surgery due to endophthalmitis. (Ophthalmology)
Example 35
Initial hospital visit for a 45-year-old patient involved in a motor vehicle accident who suffered a perforating corneoscleral laceration with vision loss. (Ophthalmology)
Example 36
Initial hospital visit for a 58-year-old male with Ludwig’s angina and progressive airway compromise. (Oral & Maxillofacial Surgery)
Example 37
Initial hospital visit for a patient with generalized systemic sclerosis, receiving immunosuppressive therapy because of recent onset of cough, fever, and inability to swallow. (Dermatology)
Example 38
Initial hospital visit for an 82-year-old male who present with syncope, chest pain, and ventricular arrhythmias. (Cardiology)
Example 39
Initial hospital visit for a 62-year-old male with history of previous myocardial infarction, comes in with recurrent, sustained ventricular tachycardia. (Cardiology)
Example 40
Initial hospital visit for a chronic dialysis patient with infected PTFE fistula, septicemia, and shock. (Nephrology)
Example 41
Initial hospital visit for a 1-year-old male, victim of child abuse, with central nervous system depression, skull fracture, and retinal hemorrhage. (Family Medicine/Neurology)
Example 42
Initial hospital visit for a 25-year-old female with recent C4-C5 quadriplegia, admitted for rehabilitation. (Physical Medicine & Rehabilitation)
Example 43
Initial hospital visit for an 18-year-old male, post-traumatic brain injury with multiple impairment. (Physical Medicine & Rehabilitation)
Example 44
Initial partial hospital admission for 16-year-old male, sullen and subdued, with six-month history of declining school performance, increasing self-endangerment, and resistance to parental expectations. (Psychiatry)
Example 45
Initial hospital visit for a 16-year –old primigravida at 32-weeks gestation at 32-weeks gestation with severe hypertension (200/110), thrombocytopenia, and headache. (Obstetrics & Gynecology)
Example 46
Initial hospital visit for a 49-year-old male with cirrhosis of liver with hematemesis, hepatic encephalopathy, and fever. ((gastroenterology)
Example 47
Initial hospital visit for a 70-year-old male, with multiple organ system disease, admitted with history of being aneuric and septic for 24 hours prior to admission. (Urology)
Example 48
Initial hospital visit for a 3-year-old female with 36 hour history of sore throat and high fever, now with sudden onset of lethargy, irritability, photophobia, and unchal rigidity. (Internal Medicine)
Example 49
Initial hospital visit for a 78-year-old male, transfer from nursing home with dysuria and pyuria, increasing confusion, and high fever. (Internal Medicine)
Example 50
Initial hospital visit for a 1-day-old male with cyanosis, respiratory distress, and tachypnea. (Cardiology)
