99232 CPT Code (2023) | Description, Guidelines, Reimbursement, Modifiers & Clinical Examples

The 99232 CPT code is used for billing services when rendered after the first visit of a patient’s inpatient hospital admission by a clinician or supervising physician, or other qualified healthcare professionals.

CPT code 99232 is reported on a day-by-day basis and is appropriate to report for either a new or established patient. 

99232 CPT Code | Description & Explanation

Subsequent hospital care is reported by three CPT codes (99231-99233). These categories (CPT Codes 99231-99233) require at least two key components out of 3 Components.

Description

NOTE: This article focuses on the description of CPT 99232 from 2013 until 2023. This code has been updated in 2023.

The official description of CPT 99232 (2013 – 2022): “Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these three key components:

• An expanded problem focused interval history;
• An expanded problem focused examination;
• Medical decision making of moderate complexity.

Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs.

Usually, the patient is responding inadequately to therapy or has developed a minor complication. Typically, 25 minutes are spent at the bedside and on the patient’s hospital floor or unit.”

Explanation

CPT 99231 requires problem-focused examination and problem-focused history. A low level of MDM is needed and typically requires 15 minutes of total time spent by the physician and other qualified health clinicians.

For instance, the patient presents minor or self-limited problems like minor traumatic injury of an extremity. CPT 99232 requires expanded problem history and examination with a moderate MDM level, typically requiring 25 minutes of total time.

For example, a patient presented with flank pain, hematuria, head injury, and loss of consciousness is considered moderate complexity of MDM.

CPT code 99233 will be billed when a physician or other clinician makes detailed history and examination, which requires 35 minutes spent on the patient’s hospital floor or unit. 

All these 3 CPT following inpatient care codes require the following elements:

• Medical records reviewed by a physician
• Diagnostic test results
• Update the status of patients from the last visit. Changes were made for the patient’s treatment and medication decision-making and any changes to the patient’s status, such as physical condition response to treatments.

CPT 99232 cannot be billed on the date of the patient’s admission, and it would be considered from 2nd day of the hospital decision.

An emergency hospital visit and same-day discharge inpatient or observation status cannot be billed with 99232 CPT on the same day by the same physician.

Documentation must support the nature of the problem and treatment decisions that were medically necessary and appropriate.

CPT (Current Procedural Terminology) 99232 is billed when subsequent hospital care is provided to a patient in one day by a physician or other qualified healthcare professional, and it requires 2 out of three components that must be met, which are as follows:

• An expanded problem focused interval history
• An expanded problem focused examination
• Medical decision making of moderate complexity

If the service is provided to a patient by a Counseling physician, and/ or coordination of care by agencies or other qualified healthcare professionals must reflect the patient’s current condition and treatment of the patient and/or family needs.

CPT 99232 could be reported based on MDM (Medical Decision Making) or Time. It typically needs 25 minutes of the physician during the coordination of care time spent on the patient’s floor or unit.

Billing Guidelines

CPT 99232 is appropriate to the bill when a second hospital inpatient visit occurs by a Physician or other healthcare qualified Clinician.

CPT code 99232 does not differentiate between new patients and established ones. It can be billed with either a new patient or an established patient.

CPT 99232 requires 2 out of 3 components which are as follows:

Expanded problem-focused history: It requires at least 1-3 HPI elements, one ROS system, and one history component is required 1 out of 3 components (PFSH).

Expanded problem-focused Exam: It requires 2-4 systems as 95 documentation and 6-11 bullets required for 97 documentation.

Moderate MDM: It requires at least 2 out of three components of MDM that must be met based on risk, diagnostic or treatment, Data management services like Medicine, Laboratory Medicine, Medicine, Medicine, review, counseling, and interpretation of services. If time is mentioned in the medical notes, it is appropriate to bill based on time instead of MDM, which typically requires 25 minutes on the patient’s hospital floor or unit.

Only one service can be provided for CPT 99232 in one day by the same physician or another qualified healthcare professional.

CPT 99232 can be billed together with Initial hospital care visit CPT codes (99221-99223), and the modifier is also not applicable according to NCCI (National Correct Coding Initiative).

Similarly, CPT 99232 can be billed with same-day Hospital discharge service CPT codes (99238-99239). Moreover, it is also allowed to be billed with same-day Inpatient status or Observation status CPT Codes (99234-99236) 

Emergency CPT codes (99281-99285) are also not allowed to bill with CPT 99232, and the modifier is also not applicable.

Q3014 is applicable when the hospital provides telemedicine service as an origin site to other outpatient hospital patients.

Modifiers

Modifier 25 will be appended with CPT code 99232 when services are done in conjunction with other services not customarily billed together on the same day.

While 24 will be appended with services done in the postoperative period with unrelated procedures or services.

Modifier 95 will be attached to the 99232 code if service is provided as a telehealth visit.

Reimbursement

The reimbursement for CPT 99232 includes the total cost and RUVS and are as follows:

• RUVS 2.20 and cost $76.21 for Non-facility
• RUVS 2.20 and cost $76.21 for the Facility

If telehealth services are provided to a patient, it is appropriate to bill CPT 99232 by appending modifier 95. Likewise, it is appropriate to bill CPT code Q3014 when the Hospital provides telehealth service to an outpatient patient. 

Billing Examples

Below you can find six billing examples of CPT code 99232.

Example 1

The patient is a thirty-nine-year-old male without medical problems for follow-up inpatient hospital visits after a slip and fall evaluation. Pt was intoxicated and fell, hitting the back of his head.

He did not suffer any LOC, nausea, or vomiting. However, he has continued to bleed from the large laceration on his head, so he presents to the ED for further evaluation.

VSS stable. Physical shows a 7 cm laceration to the occiput that is actively bleeding. CT head, washout, and staple.

Billing:

CPT Codes:

• CPT 99232: Subsequent hospital care, per day, for the evaluation and management of a patient (includes the review of systems and examination): This code is used for the patient’s follow-up inpatient hospital visit after the slip and fall evaluation.
• CPT 70450: Computed tomography, head or brain; without contrast material: This diagnostic test is ordered to evaluate the patient’s head injury after the fall.
• CPT 12002: Repair, simple, of 2.6 cm to 7.5 cm scalp, neck, external genitalia,trunk and/or extremities (excluding hands and feet): This code is used for the washout and staple repair of the 7 cm laceration on the patient’s occiput.

ICD-10 Codes:

• ICD-10 W01.0XXA: Fall on same level from slipping, tripping, and stumbling without subsequent striking against an object, initial encounter: This code is used to document the patient’s slip and fall accident while intoxicated.
• ICD-10 S00.01XA: Contusion of scalp, initial encounter: This code is used to document the patient’s contusion from the fall.
• ICD-10 S01.01XA: Laceration without foreign body of scalp, initial encounter: This code documents the patient’s 7 cm laceration on the occiput.

Example 2 

A 65-year-old male who denies medical history was admitted yesterday to evaluate lower back pain status post rear-end MVC.

The patient reports he was a restrained driver in a vehicle that stopped at a stoplight when the car behind him hit the brakes and slid into the rain, striking him in the rear end. He reports cosmetic damage to the vehicle, still an operative condition.

He denies any airbag deployment and has self-extrication from the vehicle. He reports initially having no pain, but as time passed, he began to feel a tightness in the right side of his lower back.

He denies any saddle anesthesia, incontinence of bladder or bowel, urinary retention, history of IV drug use, or history of cancer. He denies head trauma or loss of consciousness. The physician orders multiple diagnostics tests and medications for treatment.

Billing:

CPT Codes:

• CPT 99223: Initial hospital care, per day, for the evaluation and management of a patient (includes the review of systems and examination): This code is used to initial assess the patient’s condition and management plan in the hospital setting.
• CPT 72148: Magnetic resonance (e.g., MRI), lumbar spine; without contrast material.: This diagnostic test is ordered to evaluate the patient’s lower back pain and to assess for any potential injuries to the lumbar spine.
• CPT 72040: Radiologic examination, spine, cervical; 2 or 3 views: This diagnostic test is ordered to assess whether the patient has any cervical spine injuries resulting from the motor vehicle accident.
• CPT 72070: Radiologic examination, spine, thoracic; 2 views: This diagnostic test is ordered to assess whether the patient has any thoracic spine injuries resulting from the motor vehicle accident.
• CPT 72020: Radiologic examination, spine, entire, survey study, anteroposterior and lateral: This diagnostic test is ordered to provide a comprehensive view of the patient’s entire spine and evaluate potential injuries.

ICD-10 Codes:

• ICD 10 V89.2XXA: Person injured in unspecified motor-vehicle accident, initial encounter. This code documents the patient’s involvement in a motor vehicle accident, which is the cause of his lower back pain.
• ICD 10 M54.5: Low back pain: This code documents the patient’s chief complaint of lower back pain from the motor vehicle accident.
• ICD 10 S33.5XXA: Sprain of ligaments of lumbar spine, initial encounter: This code is used to document any potential injuries to the ligaments of the lumbar spine.
• ICD 10 Z13.850: Encounter for screening for traumatic brain injury. This code is used to document the patient’s denial of head trauma or loss of consciousness and the need to assess whether they have suffered a traumatic brain injury due to the accident.

Modifiers:

• Modifier 25: Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service: This modifier indicates that the initial hospital care and ordering of diagnostic tests were separate and distinct services provided to the patient on the same day.

Example 3

A 26-year-old male with h/o COPD for subsequent care hospital visit for c/o atraumatic pain and swelling to the medial aspect of right elbow x 4 days. This morning developed left upper back pain, intermittent stools, and mild nausea over the past seven days.

The patient reports having a fear of dying and feels very nervous. The patient is currently undergoing physical therapy for right shoulder pain. The patient denies fever, chills, vomiting, abdominal pain, palpitations, shortness of breath, chest pain, urinary complaints. The physician ordered CT and X-rays of the shoulders.

Billing:

CPT Codes:

• CPT 99232: Subsequent hospital care, per day, for the evaluation and management of a patient (includes the review of systems and examination: This code is used because the patient is already admitted to the hospital and this is a subsequent care visit.
• CPT 72141: Magnetic resonance (e.g., MRI), cervical spine; without contrast material: This diagnostic test is ordered to evaluate the patient’s left upper back pain and potential cervical spine issues.
• CPT 73030: Radiologic examination, shoulder, complete, minimum of 2 views: This diagnostic test is ordered to assess the patient’s right shoulder pain and evaluate the progress of the ongoing physical therapy.

ICD-10 Codes:

• ICD 10 J44.9: Chronic obstructive pulmonary disease, unspecified: This code is used to document the patient’s history of COPD.
• ICD 10 M25.521: Pain in right elbow: This code documents the patient’s complaint of atraumatic pain and swelling in the right elbow.
• ICD 10 M54.6: Pain in thoracic spine (for left upper back pain: This code documents the patient’s left upper back pain.
• ICD 10 R19.7: Diarrhea, unspecified: This code is used to document the patient’s intermittent stools.
• ICD 10 R11.0: Nausea: This code documents the patient’s mild nausea.
• ICD 10 F41.8: Other specified anxiety disorders (for fear of dying and nervousness): This code documents the patient’s fear of dying and nervousness about their medical condition.

Example 4

The patient is a 46-year-old male with a PMHx of Thyroid cancer c/b dysphagia s/p G-tube placement in 2017 who had a follow-up visit with G-tube issues.

The patient states that he came to the hospital because his G-tube suddenly popped out without clear cause three days ago. He was able to replace the tube without difficulty.

However, he has acute worsening chronic pain and discharges at the stoma that began in May 2018 after tube replacement in an outside emergency department.

He describes dark brown discharge, occasional mild bleeding at the site, and pain that has waxed and waned in intensity. The physician ordered medicine and diagnostic studies for further evaluation.

Billing:

CPT Codes:

• CPT 99213: Office or other outpatient visit for the evaluation and management of an established patient: This code is used for the follow-up visit addressing the patient’s G-tube issues.
• CPT 43760: Change of gastrostomy tube, percutaneous, without imaging or endoscopic guidance: This code represents the patient’s self-replacement of the G-tube.

ICD-10 Codes:

• ICD-10 C73: Malignant neoplasm of the thyroid gland: This code documents the patient’s history of thyroid cancer.
• ICD-10 R13.10: Dysphagia, unspecified: This code documents the patient’s dysphagia resulting from thyroid cancer.
• ICD-10 Z43.1: Encounter for attention to gastrostomy: This code documents the follow-up visit related to the patient’s G-tube issues.
• ICD-10 K94.23: Mechanical complication of gastrostomy tube: This code is used to document the patient’s issues with the G-tube, such as the dark brown discharge, occasional mild bleeding, and pain at the site.

Example 5

A 29-year-old male with a PMH of obesity and a strong family cardiac history was admitted to the hospital two days ago for chest pain x 4 days. He reports an intermittent sometimes stabbing and other times tugging sensation, which lasts 6 to 7 minutes.

He denies radiation. He is reporting some new-onset pain with breathing today. The patient is not currently experiencing symptoms while being evaluated. He reports an episode of chest pain in the waiting room.

The patient also reports random palpitations during which he feels his heart is beating very strongly. The physicians ordered other laboratory, radiology tests, and medication treatment. If the results are expected, the patient will be discharged tomorrow after evaluation.

Billing:

CPT Codes:

• CPT 99233: Subsequent hospital care, per day, for the evaluation and management of a patient (includes the review of systems and examination): This code is used for the patient’s hospital visit addressing chest pain and new-onset pain with breathing.
• CPT 93000: Electrocardiogram, routine ECG with at least 12 leads, with interpretation and report: This diagnostic test is ordered to evaluate the patient’s heart function and potential cardiac issues related to chest pain and palpitations.
• CPT 71020: Radiologic examination, chest, 2 views, frontal and lateral: This diagnostic test is ordered to evaluate the patient’s chest pain and new-onset pain with breathing.

ICD-10 Codes:

• ICD-10 E66.9: Obesity, unspecified: This code documents the patient’s history of obesity.
• ICD-10 Z82.49: Family history of ischemic heart disease and other circulatory system diseases: This code documents the patient’s strong family cardiac history.
• ICD-10 R07.89: Other chest pain: This code documents the patient’s chest pain lasting 6 to 7 minutes.
• ICD-10 R06.09: Other forms of dyspnea: This code documents the patient’s new-onset pain with breathing.
• ICD-10 R00.2: Palpitations: This code documents the patient’s random palpitations during which he feels his heart is beating very strongly.