How To Use CPT Code 99231

The CPT code 99231 pertains to subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient.

This medical billing code is used to depict a service provided by a healthcare agent that includes a medically appropriate history and/or examination and straightforward or low level of medical decision making. If you’re considering total time on the day of encounter for code selection, attaining or surpassing 25 minutes is a requisite.

CPT 99231 updated in 2023 and has the following description: “Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. When using total time on the date of the encounter for code selection, 25 minutes must be met or exceeded.”

Short description: Subsequent hospital care.

Procedure for CPT Code 99231

The patient’s medical history and/or a medically appropriate examination is reviewed. The patient’s condition is evaluated and the level of medical decision making needed is ascertained.

Essential counselling and education are imparted to the patient or caregiver. The health care provider orders tests or treatments as mandated and communicates with other healthcare providers implicated in the patient’s care.

The encounter is documented, comprising the history, examination, and medical decision making. The health care provider translates and delivers test results to the patient or caregiver and coordinates care with other healthcare professionals or agencies as required.

Qualifying circumstances CPT Code 99231

Those patients who are in a hospital inpatient or observation setup and call for subsequent evaluation and management services are eligible for CPT code 99231 services.

The patient’s condition must comprise of a straightforward or low level of medical decision making, or the healthcare professional is mandated to spend at least 25 minutes on the date of the encounter. As per the provider’s discretion, the service may include a medically suitable history and/or physical examination.

When to use CPT Code 99231

The 99231 CPT code should be billed when a healthcare professional offers subsequent hospital inpatient or observation care services for the evaluation and management of a patient, and the service requires a straightforward or low level of medical decision making or a minimum of 25 minutes of total time on the date of the encounter.

This code must not to be used for initial hospital care or discharge services.

Documentation requirements

To substantiate a claim for CPT 99231, it’s imperative to document in the patient’s medical record that the healthcare provider performed a medically suitable history and/or examination, the level of medical decision making involved in the encounter and total time spent on the day of the encounter, if using time for code selection.

Details of counselling, education, and care coordination imparted to the patient or caregiver, orders for tests or treatments, communication with other healthcare providers, interpretation and communication of test results to the patient or caregiver must be contained within the documenttation.

Billing guidelines CPT Code 99231

While billing for CPT code 99231, it’s crucial that the healthcare professionalverse ensures that the service offered meets the requisites stated in the code descriptor, taking into account the level of medical decision making or total time spent on the date of the encounter.

Proper documentation of all services offered and maintenance of precise medical records to substantiate the claim should be in place.Additionally healthcare professionals must be cognizant of any payer-specific guidelines or policies pertinent to billing for subsequent hospital care services.

Historical Information and Similar codes to CPT Code 99231

CPT 99231 was incorporated into the Current Procedural Terminology system on January 1, 1992. Several updates have been made to the code description since then, with the latest change implemented on January 1, 2023.Five codes comparable to CPT 99231 comprise CPT 99232, 99233, 99221, 99238, and 99217.

Examples of CPT Code 99231

Below you can find some examples of cases when CPT code 99231 is billed appropriately:

• a patient recuperating from pneumonia necessitating a subsequent hospital assessment to gauge their progress and modulate medications as required;
• a woman with well-regulated diabetes requiring a routine subsequent hospital visit to scrutinize blood sugar levels and address any concerns, and
• a patietn on the mend from a surgery necessitating a subsequent hospital evaluation of their wound healing processes and instructions for home care.