CPT code 99233 describes a subsequent hospital inpatient or observation care service provided by a healthcare provider, requiring a medically appropriate history and/or examination and a high level of medical decision making and the total time spent on the encounter is at least 50 minutes.
What Is CPT Code 99233?
CPT code 99233 may be used to bill subsequent inpatient or observation care services that a healthcare provider provides during a patient’s hospital stay.
The service must include a medically appropriate history and/or examination and a high level of medical decision-making by the provider. This means that the provider must have made significant and complex decisions during the service.
Secondly, the total time spent on the date of the encounter must meet or exceed 50 minutes.
The CPT book describes CPT code 99233 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 high level of medical decision making. When using total time on the date of the encounter for code selection, 50 minutes must be met or exceeded.”
In an inpatient or observation setting, a patient undergoes an evaluation and management (E/M) service provided by a healthcare provider.
This service is a follow-up for the patient’s stay, and the provider dedicates a minimum of 50 minutes or demonstrates a high level of medical decision-making (MDM) on the date of the encounter.
The time spent on this service includes both face-to-face and non-face-to-face activities, such as;
- interpreting and communicating results;
- communicating with other healthcare providers;
- reviewing test results;
- coordinating care;
- documenting the encounter;
- preparing for the patient visit;
- ordering tests; and
- educating the patient or caregiver.
How To Use CPT 99233
You can use CPT code 99233 only if the evaluation and management (E/M) service take between 50 and 64 minutes. If the service takes 65 minutes or more, the provider should use CPT code 99418 for prolonged services instead.
When selecting the appropriate E/M service level, the provider should consider the total time spent on the encounter or the level of medical decision-making (MDM) outlined in the code descriptor.
It is also important to note that these services should include a “medically appropriate history and/or physical examination” when performed.
The provider is responsible for determining the necessary level of history and examination for the encounter. The choice of history and examination should be appropriately documented in the medical record, but it does not affect the code selection.