CPT 99233

CPT Code 99233 – Description & Clinical Examples

This article will define CPT Code 99233, explain the medical necessity to report CPT 99233, the guidelines and clinical examples of CPT 99233.

CPT Code 99233 Description

CPT Code 99233 is defined by the CPT manual as follows (the text in Italic is the official definition of CPT 99233):

Post-hospital care, per day, to assess and treat a patient requiring at least 2 of the 3 key components:

  • Component 1: A detailed interval history
  • Component 2: A detailed investigation
  • Component 3: High complexity medical decision making

Counselling and / or coordination of care with other providers or facilities is done according to the nature of the problems and the needs of the patient and / or family. Usually the patient is unstable or has developed a major complication or major new problem.

CPT codes 99231 – 99233 are used to describe subsequent hospital care. These codes require documentation of the course of the interval, either at a problem-oriented, extended problem-oriented, or detailed level. The exam requires the same level of documentation. Documentation for medical decision making must support simple, low, medium or high complexity. The nature of the problem present will generally determine the level of medical history and physical examination required.

Doctors typically spend 35 minutes at the bedside and on the patient’s hospital floor or ward.

The CPT code 99233 generally needs documentation to show that a patient is not stable or has a major problem that is new or a complication.

Detailed interval history

Documentation needed:
– Main complaint
– Expanded history of current disease
– Expanded review of systems
– Relevant history, family and / or social history

Detailed examination

Documentation needed:
– Extended examination of the affected body areas or organ systems and any other symptomatic or related body areas or organ systems

Medical decision making that is of high complexity

Documentation needed (two of three below must be met or exceeded):
Large number of diagnoses or treatment options
– Large volume and / or complexity of data to review
– High risk of major complications, morbidity and / or mortality

CPT Code 99233 shows the highest level of care for hospital progress reports. Medicare’s acceptable reimbursement for this level of assistance is about $106 and has a value of 2.0 RVU. Normally, a patient is not stable or has developed a major complication or a new major issue.

CPT 99233 Examples

Example 1

Subsequent hospital visit for a 38-year-old male, quadriplegic with acute autonomic hyperreflexia, who is not responsive to initial care. (Physical Medicine & Rehabilitation)

Example 2

Follow-up hospital visit for a teenage female who continues to experience severely disruptive, violent, and life-threatening symptoms in a complicated multi-system illness, Family/social circumstances also a contributing factor. (Psychiatry)

Example 3

Subsequent hospital visit for a 42-year-old female with progressive systemic sclerosis (scleroderma), renal failure on dialysis, congestive heart failure, cardiac arrhythmias, and digital ulcer. (Allergy & Immunology)

Example 4

Subsequent hospital visit for a 50-year-old diabetic, hypertensive male with non responding back pain and radiating pain to the lower left extremity, who develops chest pain, cough, and bloody sputum. (Orthopaedic Surgery)

Example 5

Subsequent hospital visit for a 64-year-old female, status post-abdominal aortic aneurysm resection, with non-responsive coagulopathy, who has now developed lower Gl bleeding. (Abdominal Surgery/Colon & Rectal Surgery/General Surgery)

Example 6

Follow-up hospital care of patient with pansinusitis infection complicated by a brain abscess and asthma; no response to current treatment. (Otolaryngology/Head & Neck Surgery)

Example 7

Subsequent hospital visit for a patient with a laryngeal neoplasm who develops airway compromise, suspected metastasis. (Otolaryngology/Head & Neck Surgery)

Example 8

Subsequent hospital visit for a 49-year-old male with significant rectal bleeding, etiology undetermined, not responding to treatment. (Abdominal Surgery/General Surgery/Colon & Rectal Surgery)

Example 9

Subsequent hospital visit for a 50-year-old male, post-aortocoronary bypass surgery; now develops hypotension and oliguria. (Cardiology)

Example 10

Subsequent hospital visit for an adolescent patient who is violent, unsafe, and noncompliant, who multiple expectations for participation in treatment plan and behaviour on the treatment unit. (Psychiatry)

Example 11

Subsequent hospital visit for an 18-year-old male being treatment for presumed PCP psychosis, Patient is still moderately symptomatic with auditory hallucinations and is insisting on signing out against medical advice. (Psychiatry)

Example 12

Subsequent hospital visit for an 8-year-old female with caustic ingestion, who now has fever, dyspnea, and dropping hemoglobin. (Gastroenterology)

Example 13

Follow-up hospital visit for a chronic renal failure patient on dialysis who develops chest pain and shortness of breath and a new onset pericardial friction rub. (Nephrology)

Example 14

Subsequent hospital visit for a 44-year-old patient with electrical burns the left arm with ascending infection. (Orthopaedic Surgery)

Example 15

Subsequent hospital visit for a patient with systemic sclerosis who has aspirated and is short of breath. (Dermatology)

Example 16

Subsequent hospital visit for a 65-year-old female, status postoperative resection of abdominal aortic aneurysm, with suspected ischemic bowel. (General Surgery)

Example 17

Subsequent hospital visit for a 50-year-old male, post-aortocoronary bypass Surgery, now develops hypotension and oliguria. (Cardiology)

Example 18

Subsequent hospital visit for a 50-year-old male, following an acute myocardial infarction, who complains of shortness of breath and new chest pain. (Cardiology)

Example 19

Subsequent hospital visit for a 65-year-old female with rheumatoid arthritis (stage 3, class 3) admitted for urosepsis, On the third hospital day, chest pain, dyspnea, and fever develop. (Rheumatology)

Example 20

Follow-up hospital care of pediatric case with stridor, laryngomalacia, established tracheostomy, complicated by multiple medical problems in PICU. (Otolarygology/Head & Neck Surgery)

Example 21

Subsequent hospital visit for a 60-year-old female, four days post uncomplicated inferior myocardial infraction who has developed severe chest pain, dyspnea, diaphoresis, and nausea. (Family Medicine)

Example 22

Subsequent hospital visit for a patient with AMLL (acute myelogenous leukemia), fever, elevated white count and uric acid undergoing induction chemotherapy. (Hematology/Oncology)

Example 23

Subsequent hospital visit for a 38-year-old quadriplegic male with acute autonomic hyperreflexia, who is not responsive to initial care. (Physical Medicine & Rehabilitation)

Example 24

Subsequent hospital visit for a 65-year-old female postoperative resection of abdominal aortic aneurysm, with suspected ischemic bowel. (General Surgery)

Example 25

Subsequent hospital visit for a 60-year-old female with persistent leukocytosis and a fever seven day after a sigmoid colon resection for carcinoma. (Infectious Disease)

Example 26

Subsequent hospital visit for a chronic renal failure patient on dialysis, who develops chest pain, shortness of breath, and new onset pericardial friction rub. (Nephrology)

Example 27

Subsequent hospital visit for a 65-year-old male with acute myocardial infraction who now demonstrates complete heart block and congestive heart failure. (Cardiology)

Example 28

Subsequent hospital visit for a 25-year-old female with hypertension an systemic lupus erythematosus, admitted for fever and respiratory distress, On the third hospital day, the patient presented with purpuric skin lesions and acute renal failure. (Allergy & Immunology)

Example 29

Subsequent hospital visit for a 55-year-old male with severe chronic obstructive pulmonary disease and bronchospasm; initially admitted for acute respiratory distress requiring ventilator support in the ICU. The patient was stabilized, extubated, and transferred to the floor but has now developed acute fever, dyspnea, left lower lobe rhonchi, and laboratory evidence of carbon dioxide retention and hypoxemia. (Family Medicine/Internal Medicine)

Example 30

Subsequent hospital visit for 46-year-old female, known liver cirrhosis patient, with recent upper gastrointestinal hemorrhage from varices; now with worsening ascites and encephalopathy. (Gastroenterology)

Example 31

Subsequent hospital visit for 62-year-old female admitted with acute subarachnoid hemorrhage, hegative cerebral arteriogram, increased lethargy, and hemiparesis with fever. (Neurosurgery)

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