CPT 99231, cpt code 99231, 99231 cpt code

CPT 99231 | Subsequent Visit | E/M | Hospital Or Observation Setting

CPT 99231 describes a subsequent hospital inpatient or observation care visit for evaluation and management services (E/M) of at least 25 minutes or more. 

What Is CPT Code 99231?

CPT code 99231 can be used to report a subsequent hospital inpatient or observation care visit involving a patient’s evaluation and management (E/M).

The provider will take a history of the patient’s condition and/or perform a physical examination during the visit.

The level of medical decision-making involved in the visit is low, so a provider will not make complex or high-risk decisions regarding the patient’s care.

A minimum of 25 minutes of total time must be spent on the encounter on a single date. This includes face-to-face and non-face-to-face activities.

Description

The CPT book describes CPT code 99231 as: “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.”

Procedure

The provider conducts a subsequent visit with a patient currently receiving inpatient or observation care in a hospital setting.

The visit involves an evaluation and management (E/M) service and is intended to assess the patient’s current condition, progress, and any necessary changes to their treatment plan.

The level of medical decision-making (MDM) involved in this encounter is low, and the provider spends at least 25 minutes on the encounter on a single date.

The total time spent on the encounter’s date includes face-to-face and non-face-to-face activities related to the patient’s care.

This can include reviewing and analyzing patient data, discussing treatment options with other healthcare providers, and documenting the encounter in the patient’s medical record.

The provider may also take a patient history and perform a physical examination during the encounter.

The provider will determine the nature and extent of the history and/or exam based on the patient’s current condition and the visit’s goals.

The provider will use this information to make informed decisions about the patient’s care and develop an appropriate treatment plan.

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