cpt 99221

CPT Code 99221 – Description & Clinical Examples

This article will define CPT Code 99221, explain the medical necessity to report CPT 99221, the guidelines and clinical examples of CPT 99221.

CPT Code 99221 Description

CPT Code 99221 is defined by the CPT manual as follows (the text in Italic is the official definition of CPT 99221):

Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components:

  • Component 1: A detailed or comprehensive history
  • Component 2: A detailed or comprehensive examination
  • Component 3: Medical decision making that is straightforward or of low complexity

Counselling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the problem(s) requiring admission are of low severity.

Physicians typically spend 30 minutes at the bedside and on the patient’s hospital floor or unit.

Complete or Comprehensive History

Documentation Required:

Primary Complaint

Extended History of Current Illness

Detailed: Extended review of systems; pertinent past, family and or social history

Comprehensive: Complete review of systems, complete past, family and social history

Detailed or Comprehensive Examination

Documentation Required:

Detailed: Extended examination of the affected body area(s) or organ system(s) and any other symptomatic or related body area(s) or organ system(s)

Comprehensive: General multi-system examination or complete examination of a single organ system and other symptomatic or related body area(s)or eight or more organ system(s)

Medical Decision Making (straightforward or of low complexity)

Documentation Required (two of three below must be met or exceeded):

Straightforward: Minimal number of diagnoses or management options, none or minimal amount and/or complexity of data to be reviewed, minimal risk of significant complications, morbidity and/or mortality

Low complexity: Limited number of diagnoses or management options, limited amount and/or complexity of data to be reviewed, low risk of significant complications, morbidity and/or mortality

CPT 99221 – 99223 Initial Hospital Care Services Payment

Initial Hospital Care From Emergency Room Carriers pay for initial hospital care or initial inpatient counselling when a doctor views their patient in an emergency room or is determined to admit the patient to a hospital.

You don’t pay for both E / M services. Also, you don’t pay for an emergency room visit from the same doctor on the same day of service. If the patient is admitted to the hospital in 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 reviewed in practice one day and hospitalised the following day, even if less than two hours have passed from the visit and the admission.

Initial Hospital Care and Discharge on Same Day Carriers
pay the hospital initial care CPT code if a patient is admitted then discharged the same day.

You don’t need to pay the hospital discharge management CPT code on the day of admission. Carriers must inform physicians not to bill a hospital initial care CPT code and a hospital discharge management CPT code at the same time.

The following may bill both the hospital discharge management CPT code and an initial hospital care code when the discharge and admission don’t happen on the same day if the transfer is between different hospitals, different facilities under similar ownership which don’t have their records merged or between the acute care hospital and a PPS exempt unit within the same hospital when the records are not merged:

Physician Services Involving Transfer From One Hospital to Another

Transfer Within Facility to Prospective Payment System (PPS) Exempt Unit of Hospital

Transfer From One Facility to Another Separate Entity Under Same Ownership and/or Part of Same Complex

Transfer From One Department to Another Within Single Facility Physicians

CPT Code 99221 Examples

Example 1

Initial hospital visit following admission for a 42-year-old male for observation following an uncomplicated mandible fracture. (Plastic Surgery/Oral & Maxillofacial Surgery)

Example 2

Initial hospital visit for a 40-year-old patient with a thrombosed synthetic arteriovenous conduit. (Nephrology)

Example 3

Initial hospital visit for a healthy 24-year-old male with an acute onset of low back pain following a lifting injury. (Internal Medicine/Anesthesiology/Pain Medicine)

Example 4

Initial hospital visit for a 69-year-old female with controlled hypertension, scheduled for surgery. (Internal Medicine/Cardiology)

Example 5

Initial hospital visit for a 24-year-old healthy female with benign tumor of palate. (Oral & Maxillofacial Surgery)

Example 6

Initial hospital visit for a 14-year-old female with infectious mononucleosis and dehydration. (Internal Medicine)

Example 7

Initial hospital visit for a 62-year-old female with stable rheumatoid arthritis, admitted for total joint replacement. (Rheumatology)

Example 8

Initial hospital visit for a 12-year-old patient with a laceration of the upper eyelid, involving the lid margin and superior canaliculus, admitted prior to surgery for IV antibiotic therapy. (Plastic Surgery)

Example 9

Initial hospital visit for a 69-year-old female with controlled hypertension, scheduled for surgery. (Cardiology)

Example 10

Hospital admission, examination, and initiation of treatment program for a 67-year-old male with uncomplicated pneumonia who requires IV antibiotic therapy. (Internal Medicine)

Example 11

Hospital admission for an 18-month-old with 10% dehydration. (Pediatrics)

Example 12

Hospital admission for a 12-year-old with a laceration of the upper eyelid involving the lid margin and superior canaliculus, admitted prior to surgery for IV antibiotic therapy. (Ophthalmology)

Example 13

Hospital admission for a 32-year-old female with severe flank pain, hematuria, and presumed diagnosis of ureteral calculus as determined by Emergency Department physician. (Urology)

Example 14

Initial hospital visit for a patient with several large venous stasis ulcers not responding to outpatient therapy. (Dermatology)

Example 15

Initial hospital visit for 21-year-old pregnant patient (nine-weeks gestation) with hyperemesis gravidarum. (Obstetrics & Gynecology)

Example 16

Initial hospital visit for a 73-year-old female with acute pyelonephritis who is otherwise generally healthy. (Geriatrics)

Example 17

Initial hospital visit for a 62-year-old patient with cellulitis of the foot requiring bed rest and intravenous antibiotics. (Orthopaedic Surgery)

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