99231 CPT code

99231 CPT Code (2022) Description, Guidelines, Reimbursement, Modifiers & Examples

99231 CPT code may define as a medical procedure code for Subsequent Hospital Care Services, according to American Medical Association (AMA). CPT code 99231 may explain as “Established” hospital inpatients have their E/M services provided using this service level during “subsequent visits” following the initial inpatient encounter. 


An established patient has seen the same doctor, another doctor in the group practice, or another doctor in the same specialty who bills under the same group number in the previous 36 months. It is the most widely accepted definition of “established patient.” 

For the 99231 CPT code, two of the three required components must be present at all times for the service level to be supported. Every day in the hospital, evaluating and managing a patient who requires at least two of the three required elements: a problem-focused examination, a problem-focused interval history, and simple or low-complexity medical decisions are examples of problem-focused medical decisions. 

Care coordination with other organizations or providers may offer depending on the nature of the problem and the patient’s and family’s needs. Typically, the patient is stable, progressing, or recovering. 99231 CPT code – 99233 may describe follow-up hospital care, with clinicians typically spending 15 minutes at the patient’s bedside and on the hospital floor or unit. 

99231 CPT Code Description

99231 CPT code may follow when describing the interval history’s details, expansions, and problem-focused aspects. The same level of documentation may require for the examination—all medical decisions, whether simple, moderate, or complex, must be supported by documentation.

The severity of an issue usually dictates the scope of a patient’s history and examination.

99231 CPT code frequently necessitates supporting documentation to help stabilize, recover, or improve the patient.CPT code 99232 typically requires confirmation that the patient did not respond well to treatment or had a minor problem. 

One of these minor issues could be the requirement for ongoing active management of co-occurring illnesses. Before payment, CPT code 99231 requires medical documentation and a manual evaluation of the service by the contractor. In these cases, contractors must plan ahead of time for unexpected reporting.

Medicare’s contractors have warned patients to expect changes in how doctors bill. Contractors will not hold providers liable for subsequent hospital care codes if the medical record shows that the task and medical necessity standards were met (99231 CPT code and 99232).

Collaboration with other healthcare professionals and organizations is vital for improving your operations. Counseling and treatment will be tailored to the family’s individual needs to ensure their needs may address.

Medical necessity and critical component work criteria for essential hospital care services may not meet. As a result, CPT consultation codes 99251 and 99252 may utilize to meet reporting requirements for an E/M service denoted by 99231 CPT code and 99232. 

Contractors may prepare when it comes to medical billing procedures. Even if they are not overseeing the patient’s treatment on behalf of the first doctor, the second doctor must utilize CPT codes 99231 – 99233 for the final appointment.

To receive extra hospital treatment, CPT codes 99231 and 99232 require a lengthy problem-focused interval history. 

Medicare will cover the costs of pre- and post-service work and the documentation required to justify those expenditures for E/M services. If the documentation can amend to a later date, the date of death may reflect the actual death declaration’s calendar date.

cpt code 99231

99231 CPT Code Billing Guidelines 

In the case of 99231 CPT code, when extra hospital care may consider, all diagnostic results and any changes in a patient’s condition since their last evaluation may include in the medical record. Change may see in history, the physical world, and the actions of those in positions of authority.

Coordination with other licensed health care practitioners and agencies is critical in improving your procedures. The following questions should guide your review of the document:

The history is either a problem-focused history or an extended history of the problem. Remember that an interval history summarises the patient’s progress since the last appointment.

Second, what kind of test is it?

What is the level of making medical decisions? There are three levels of complexity: low, moderate, and high.

Was the doctor at the patient’s bedside for an extended period? The duration of the illness increases as it progresses. It will aid you in selecting the correct CPT code.

After the first hospital visit for established inpatients, evaluation and management services may document using 99231 CPT code. There may be patients who may treat by the same doctor for at least 36 months, regardless of whether that doctor. In this case, there are the following three components in the documentation.

Component 1: A problem-focused investigation may include

Component 2: Problem-centered interval history.

Component 3: Ability to make straightforward medical decisions.

The highest documented pair of the three components indicated above defines the relevant code among all hospital follow-up billing codes (99231 CPT code, 99232, and 99233). Most people report having the greatest need for all three components during the first three components of hospital patient care visits. 

To reiterate, only the two most important components are required to determine the appropriate patient care level. The following section goes over the minimum 99231 CPT code requirements.

The Problem-Focused Interval History (PFIH) or documentation of three long-term medical conditions must complete with as few as 1-3 components. As previously stated, only one HPI component will require.

The patient is not required to provide previous medical, social, or family background information, and no systematic review is needed.

A problem-solving physical exam: There are one to five organ systems (1997 guidelines). One organ system may make up three essential signals. Only three vital signs must check to bill for low-level follow-up care. 

The CMS E&M manual specifies which organ systems and body components must examine during a physical examination. Making simple or straightforward medical decisions (MDM) This may divide into three parts. The two highest MDM readings may use to calculate the overall MDM level. 

A multi-tiered point and risk system determines the difficulty level. What are the Marshfield Clinic audit tool’s minimum point and risk requirements and the three MDM components?

99231 CPT Code Modifiers

When a clinician performs an E/M and a minor surgical treatment on the same day, modifier 25 may use for the 99231 CPT code. The physician must document both the E/M service and the non-E/M service in their separate records. 

Above and beyond what may generally require for the process, the E/M service must have additional requirements for history, exam, expertise, ability, labor time, and risk. The procedure must have documentation; none of the E/M service documentation components may also support its execution.

Modifier 59 may use to identify procedures or services that are not typically reported concurrently, such as surgeries. Modification 59 is defined in the AMA’s CPT 2012 as follows:

  • In some cases, it may be necessary to specify that a method or service was distinct from other non-E/M services performed on the same day. 

Aside from E/M services, the modifier 59 may identify procedures and services that are not typically reported together but are appropriate in the current situation. A treatment that takes 90 days to complete may consider significant globally. 

If a CPT modifier 57 indicates that the service led to the decision to perform the procedure, Medicare may require to pay for an evaluation and management (E/M) service. The operation fee does not include an evaluation to determine whether or not a patient will have surgery.

The modifiers used for the 99231 CPT code are 25, 59, and 57.

99231 CPT Code Reimbursement

The most basic level of care for hospital progress notes is 99231 CPT code. Internists handled only 5.17 percent of these encounters using the 99231, making it the minor ordinary level of therapy in 2018. RVUs for this level of service may typically charge at a rate of $40 per RVU.


We had to code each of an 80-year-old patient’s visits after he was admitted to the hospital for six days with a suspected case of pneumococcal pneumonia and low oxygen saturation.

99231 CPT code requires extensive background research and a physical examination, but the current state of affairs does not warrant those measures. On the first day after admission, the patient remains tachypneic, has low oxygen saturation, and is feverish. While the cultures must process, the patient receives oxygen and broad-spectrum antibiotics.

CPT code 99232 requires a physical examination and a medical history that consistently falls short of the required standards. The second day after admission, there was less tachypnea, a constant temperature, oxygen therapy, and broad-spectrum antibiotics. Because no specific pathogen may find in the culture, the current drugs will not change.

In other words, the patient’s condition has dramatically improved. Antibiotics administered intravenously may keep in the system for one more day. The patient’s condition is improving. Based on the patient’s current health, CPT code 99231 appears justified.

Fourth post-admittance day, alert with high oxygen saturation in the room. IV antibiotics are no longer required, and the patient may prescribe oral antibiotics instead. The patient is improving and will soon wholly recover. For CPT code 99231, it appears that the patient’s condition justifies the level of history and physical examination required.

The patient is discharged five days after admission, and the appropriate discharge code will invoice to the insurance company at that time.

Examples Continued

The following examples are when the 99231 CPT code may be used.

Example 1

Subsequent hospital visit for a 65-year-old female, post-open reduction and internal fixation of a fracture. (Physical medicine & Rehabilitation)

Example 2

Subsequent hospital visit for a 33-year-old patient with pelvis pain who is responding to pain medication and observation. (Obstetrics & Gynecology)

Example 3

Subsequent hospital visit for a 21-year-old female with hyperemesis who has responded well to intravenous fluids. (Obstetrics & gynecology)

Example 4

Subsequent hospital visit to re-evaluate postoperative pain and titrate patient-controlled analgesia for a 27-year-old female. (Anesthesiology)

Example 5

Follow-up hospital visit for a 35-year-old female, status post-epidural analgesia. (Anesthesiology/Pain Medicine)                           

Example 6

Subsequent hospital visit for a 56-year-old male, post-gastrectomy, for maintenance of analgesia using an intravenous dilaudid infusion. (Anesthesiology)

Example 7

Subsequent hospital visit for a 4-year-old on day three receiving medication for uncomplicated pneumonia. (Allergy & Immunology)

Example 8

Subsequent hospital visit for a 30-year-old female with urticaria that has stabilized with medication (Allergy & Immunology)

Example 9

Subsequent hospital visit for a 76-year-old male with venous stasis ulcers. (Dermatology)

Example 10

Subsequent hospital visit for a 24-year-old female with otitits externa, seen two days before in consultation, now to have otic wick removal. (Otolaryngology/Head & Neck Surgery)

Example 11

Subsequent hospital visit for a 27-year-old with acute labyrinthitis. (Otolaryngology/Head & Neck surgery)

Example 12

Subsequent hospital visit for a 10-year-old male admitted for lobar pneumonia with vomiting and dehydration; is becoming afebrile and tolerating oral fluids. Family Medicine/Pediatrics)

Example 13

Subsequent hospital visit for a 62-year-old patient with resolving cellulitis of the foot. (Orthopaedic Surgery)

Example 14

Subsequent hospital visit for a 25-year-old male admitted for supra-ventricular tachycardia and converted on medical therapy. (Cardiology)

Example 15

Subsequent hospital visit for a 27-year-old male two days after open reduction and internal fixation for malar complex fracture. (Plastic Surgery)

Example 16

Subsequent hospital visit for a 76-year-old male with venous stasis ulcers. (Geriatrics)

Example 17

Subsequent hospital visit for a 67-year-old female admitted three days ago with bleeding gastric ulcer; now stable. (Gastroenterology)

Example 18

Subsequent hospital visit for a stable 33-year-old male, status post-lower gastrointestinal bleeding. (General Surgery/Gastroenterology)

Example 19

Subsequent hospital visit for a 29-year-old auto mechanic with effort thrombosis of left upper extremity. (General Surgery)

Example 20

Subsequent hospital visit for a 14-year-old female in middle phase of inpatient treatment, who is now behaviour stable and making satisfactory progress in treatment. (Psychiatry)

Example 21

Subsequent hospital visit for an 18-year-old male with uncomplicated asthma who is clinically stable. (Allergy & Immunology)

Example 22

Subsequent hospital visit for a 55-year-old male with rheumatoid arthritis, two days following an uncomplicated total joint replacement. (Rheumatology)

Example 23

Subsequent hospital visit for a 60-year-old dialysis patient with an access infection, now afebrile on antibiotic. (Nephrology)

Example 24

Subsequent hospital visit for a 36-year-old female with stable post-rhinoplasty epistaxis. (Plastic Surgery)

Example 25

Subsequent hospital visit for a 66-year-old female with L-2 vertebral compression fracture with resolving ileus. (Orthopaedic Surgery)

Example 26

Subsequent hospital visit for a patient with peritonsillar abscess. (Otolaryngology/Head & Neck Surgery)

Example 27

Subsequent hospital visit for an 18-year-old female responding to intravenous antibiotic therapy for ear or sinus infection. (Otolaryngology/Head & Neck Surgery)

Example 28

Subsequent hospital visit for a 70-year-old male admitted with congestive heart failure who has responded to therapy. (Cardiology)

Example 29

Follow-up hospital visit for a 32-year-old female with left ureteral calculus; being followed in anticipation of spontaneous passage. (Urology)

Example 30

Subsequent hospital visit for a 4-year-old female, admitted for acute gastroenteritis and dehydration, requiring lV hydration; now stable. (Family Medicine)

Example 31

Subsequent hospital visit for a 50-year-old Type ll diabetic who is clinically stable and without complications requiring regulation of a single does of insulin daily. (Endocrinology)

Example 32

Subsequent hospital visit to reassesses the status of 65-year-old patient post-open reduction and internal fixation of hip fracture, on the rehab unit. (Physical Medicine & Rehabilitation)

Example 33

Subsequent hospital visit for a 78-year-old male with cholangiocarcinoma managed by biliary drainage. (Interventional Radiology)

Example 34

Subsequent hospital visit for a 50-year-old male with uncomplicated myocardial infarction who is clinically stable and without chest pain. (Family Medicine/Cardiology/Internal Medicine)

Example 35

Subsequent hospital visit for a stable 72-year-old lung cancer patient undergoing a five-day course of infusion chemotherapy. (Haematology/Oncology)

Example 36

Subsequent hospital visit, two days post admission for a 65-year-old male with a CVA (cerenral vascular accident) and left hemiparesis, who is clinically stable. (Neurology/Physical Medicine & Rehabilitation)

Example 37

Subsequent hospital visit for now stable, 33-year-old male, status post lower gastrointestinal bleeding. (Genera Surgery)

Example 38

Subsequent visit on third day of hospitalization for a 60-year-old female recovering from an uncomplicated pneumonia. (Infectious Disease/Internal Medicine/Pulmonary Medicine)

Example 39

Subsequent hospital visit for a 3-year-old patient in traction for a congenital dislocation of the hip. (Orthopaedic Surgery)

Example 40

Subsequent hospital visit for a 4-year-old female, admitted for acute gastroenteritis and dehydration, requiring lV hydration; now stable. (Family Medicine/Internal Medicine)

Example 41

Subsequent hospital visit for 50-year-old female with resolving uncomplicated acute pancreatitis. (Gastroenterology)

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