cpt 99231

CPT Code 99231 – Description & Clinical Examples

This article will define CPT Code 99231, explain the medical necessity to report CPT 99231, the guidelines and clinical examples of CPT 99231.

CPT Code 99231 Description

CPT Code 99231 is defined by the CPT manual as follows (the text in Italic is the official definition of CPT 99231):

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 patient is stable, recovering or improving.

Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of the 3 key components:

  • Component 1: A problem focused interval history
  • Component 2: A problem focused examination
  • Component 3: Medical decision making that is straightforward or of low complexity

Physicians typically spend 15 minutes at the bedside and on the patient’s hospital floor or unit.

• Problem focused interval history
• Chief complaint
• Brief history of present illness

Problem focused examination

Documentation needed:

  • Limited examination of the affected body area or organ system
Medical decision making that is straightforward OR of low complexity.

Documentation needed (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

The following hospital treatment CPT codes 99231 – 99232 need a problem-oriented interval history and an extended problem-oriented interval history. An E / M service that could be defined by CPT advisory code 99251 or 99252 could potentially meet the component’s labor and medical necessity requirements to report CPT 99231 or 99232.

CPT codes 99231 – 99233 are implemented to define subsequent hospital care. These CPT codes need documentation of the course of the interval, either at a problem-oriented, extended problem-oriented, or detailed level. The exam requires an equal level of documentation. Documentation for medical decision making must support simple, low, medium or high complexity. The nature of the issue in question will generally define the level of medical history and physical examination required. The CPT code 99231 generally requires documentation to demonstrate that the patient is improving, recovering, or stable.

Medicare contractors are advised to foresee appropriate changes in billing practices from physicians. Contractors won’t criticise contractors who report the hospital care codes CPT 99231 and 99232 if the medical record adequately determines that medical necessity and work requirements are met to report a subsequent hospital care CPT code (based on the level selected).

CPT Code 99231 Examples

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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