How To Use CPT Code 99236

CPT 99236 is a code used for hospital inpatient or observation care, including admission and discharge on the same date, requiring a medically appropriate history and/or examination and high 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 99236.

1. What is CPT 99236?

CPT 99236 is a code used by medical professionals to bill 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. This code requires a medically appropriate history and/or examination and a high level of medical decision making. It is essential for medical coders and billers to understand the specific requirements and guidelines associated with CPT 99236 to ensure accurate billing and reimbursement.

2. 99236 CPT code description

The official description of CPT code 99236 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 high level of medical decision making. When using total time on the date of the encounter for code selection, 85 minutes must be met or exceeded.”

3. Procedure

The 99236 procedure involves the following steps:

1. Admission of the patient to the hospital for inpatient or observation care.
2. Performing a medically appropriate history and/or examination of the patient.
3. Evaluating the patient’s condition and determining the appropriate course of treatment.
4. Managing the patient’s care, including ordering tests, coordinating with other healthcare providers, and making medical decisions.
5. Documenting the encounter, including the history, examination, and medical decision making.
6. Discharging the patient from the hospital on the same date as admission.

4. Qualifying circumstances

Patients eligible to receive CPT code 99236 services are those who require hospital inpatient or observation care, including admission and discharge on the same date. The patient’s condition must necessitate a medically appropriate history and/or examination and a high level of medical decision making. Additionally, the total time spent on the date of the encounter must be at least 85 minutes for code selection based on time.

5. When to use CPT code 99236

It is appropriate to bill the 99236 CPT code when a provider sees a patient for hospital inpatient or observation care involving evaluation and management (E/M), with an admission encounter and discharge encounter on the same date. The E/M involves a high level of medical decision making or the provider spends at least 85 minutes of total time on the service on a single date.

6. Documentation requirements

To support a claim for CPT 99236, the following information must be documented:

• Date of service
• Admission and discharge times
• Medically appropriate history and/or examination performed
• High level of medical decision making involved
• Total time spent on the date of the encounter (if using time for code selection)
• Details of the patient’s condition and treatment plan
• Coordination of care with other healthcare providers, if applicable

7. Billing guidelines

When billing for CPT code 99236, it is essential to follow the specific guidelines and rules associated with this code. Ensure that the documentation supports the claim, including the medically appropriate history and/or examination, high level of medical decision making, and total time spent on the date of the encounter (if using time for code selection). For services of 100 minutes or longer, use prolonged services code 99418.

8. Historical information

CPT 99236 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 99236

Five similar codes to CPT 99236 include:

• CPT 99234: Involves observation or inpatient hospital care with a lower level of medical decision making.
• CPT 99235: Requires a comprehensive history and examination but a moderate level of medical decision making.
• CPT 99238: Covers hospital discharge day management services with a lower level of medical decision making.
• CPT 99239: Involves hospital discharge day management services with a higher level of medical decision making.
• CPT 99418: Used for prolonged services of 100 minutes or longer.

10. Examples

Here are 10 detailed examples of CPT code 99236 procedures:

1. A patient with severe pneumonia is admitted to the hospital for observation, receives a comprehensive examination and treatment, and is discharged on the same day after improvement.
2. A patient experiencing chest pain is admitted for observation, undergoes diagnostic testing, and is discharged on the same day after ruling out a cardiac event.
3. A patient with uncontrolled diabetes is admitted for inpatient care, receives medication adjustments and education, and is discharged on the same day after stabilization.
4. A patient with an acute asthma exacerbation is admitted for observation, receives treatment, and is discharged on the same day after improvement in symptoms.
5. A patient with cellulitis is admitted for inpatient care, undergoes intravenous antibiotic therapy, and is discharged on the same day after improvement.
6. A patient with dehydration is admitted for observation, receives intravenous fluids, and is discharged on the same day after rehydration.
7. A patient with a transient ischemic attack is admitted for observation, undergoes diagnostic testing, and is discharged on the same day after ruling out a stroke.
8. A patient with an allergic reaction is admitted for observation, receives treatment, and is discharged on the same day after resolution of symptoms.
9. A patient with a urinary tract infection is admitted for inpatient care, undergoes intravenous antibiotic therapy, and is discharged on the same day after improvement.
10. A patient with a migraine is admitted for observation, receives treatment, and is discharged on the same day after relief of symptoms.