How To Use CPT Code 99235

CPT 99235 refers to hospital inpatient or observation care, including admission and discharge on the same date, requiring a medically appropriate history and/or examination and moderate level of medical decision making. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, similar codes, and examples of CPT 99235.

1. What is CPT 99235?

CPT 99235 is a medical billing code used for hospital inpatient or observation care services that involve evaluation and management (E/M) of a patient, including admission and discharge on the same date. The code requires a medically appropriate history and/or examination and a moderate level of medical decision making. It is used by medical coders and billers to accurately document and bill for these specific services provided by healthcare professionals.

2. 99235 CPT code description

The official description of CPT code 99235 is: “Hospital inpatient or observation care, for the evaluation and management of a patient including admission and discharge on the same date, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 70 minutes must be met or exceeded.”

3. Procedure

The 99235 procedure involves the following steps:

1. Admission of the patient to the hospital inpatient or observation setting.
2. Performing a medically appropriate history and/or examination.
3. Evaluating the patient’s condition and determining the level of medical decision making required.
4. Providing necessary treatment, counseling, and/or coordination of care with other healthcare providers or agencies.
5. Discharging the patient on the same date as admission.
6. Documenting the encounter, including the history, examination, medical decision making, and total time spent on the service.

4. Qualifying circumstances

Patients eligible to receive CPT code 99235 services are those who require hospital inpatient or observation care, including evaluation and management, with admission and discharge on the same date. The patient’s condition must necessitate a medically appropriate history and/or examination and involve a moderate level of medical decision making. Additionally, the total time spent on the service must be at least 70 minutes.

5. When to use CPT code 99235

It is appropriate to bill the 99235 CPT code when a healthcare provider performs evaluation and management services for a patient in the hospital inpatient or observation setting, with admission and discharge on the same date. The services must include a medically appropriate history and/or examination and involve a moderate level of medical decision making. The total time spent on the service must be at least 70 minutes.

6. Documentation requirements

To support a claim for CPT 99235, the following information must be documented:

• Date of service
• Admission and discharge times
• Medically appropriate history and/or examination performed
• Level of medical decision making involved
• Total time spent on the service, including both face-to-face and non-face-to-face activities
• Treatment, counseling, and/or coordination of care provided
• Any communication with other healthcare providers or agencies

7. Billing guidelines

When billing for CPT code 99235, it is essential to follow the appropriate guidelines and rules. Ensure that the service provided meets the requirements for a medically appropriate history and/or examination and involves a moderate level of medical decision making. The total time spent on the service must be at least 70 minutes. Additionally, all services performed should be documented appropriately in the medical record.

8. Historical information

CPT 99235 was added to the Current Procedural Terminology system on January 1, 1998. There have been several updates to the code since its addition, with the most recent change occurring on January 1, 2023.

9. Similar codes to CPT 99235

Five similar codes to CPT 99235 and how they differentiate are:

• CPT 99234: Involves hospital inpatient or observation care with admission and discharge on the same date, but requires a lower level of medical decision making or less total time spent on the service.
• CPT 99217: Covers observation care discharge services only, without the same-day admission component.
• CPT 99218: Pertains to initial observation care, without the same-day discharge component, and requires a lower level of medical decision making.
• CPT 99219: Similar to CPT 99218 but requires a higher level of medical decision making.
• CPT 99220: Similar to CPT 99219 but requires the highest level of medical decision making among initial observation care codes.

10. Examples

Here are 10 detailed examples of CPT code 99235 procedures:

1. A patient with chest pain is admitted to the hospital for observation, undergoes a thorough history and examination, and is discharged on the same day after a moderate level of medical decision making is performed.
2. A patient with dehydration is admitted to the hospital for intravenous fluid administration, receives a medically appropriate examination, and is discharged on the same day after a moderate level of medical decision making is performed.
3. A patient with an asthma exacerbation is admitted to the hospital for observation, undergoes a medically appropriate history and examination, receives treatment, and is discharged on the same day after a moderate level of medical decision making is performed.
4. A patient with cellulitis is admitted to the hospital for intravenous antibiotic administration, receives a medically appropriate examination, and is discharged on the same day after a moderate level of medical decision making is performed.
5. A patient with a transient ischemic attack is admitted to the hospital for observation, undergoes a thorough history and examination, and is discharged on the same day after a moderate level of medical decision making is performed.
6. A patient with a urinary tract infection is admitted to the hospital for intravenous antibiotic administration, receives a medically appropriate examination, and is discharged on the same day after a moderate level of medical decision making is performed.
7. A patient with a COPD exacerbation is admitted to the hospital for observation, undergoes a medically appropriate history and examination, receives treatment, and is discharged on the same day after a moderate level of medical decision making is performed.
8. A patient with a migraine headache is admitted to the hospital for observation, receives a medically appropriate examination, and is discharged on the same day after a moderate level of medical decision making is performed.
9. A patient with a minor head injury is admitted to the hospital for observation, undergoes a thorough history and examination, and is discharged on the same day after a moderate level of medical decision making is performed.
10. A patient with a suspected gastrointestinal bleed is admitted to the hospital for observation, undergoes a medically appropriate history and examination, and is discharged on the same day after a moderate level of medical decision making is performed.