How To Use CPT Code 99223

CPT 99223 describes the initial hospital inpatient or observation care for the evaluation and management of a patient. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, similar codes, and examples of CPT 99223.

1. What is CPT Code 99223?

CPT 99223 can be used to describe the initial hospital inpatient or observation care provided by a healthcare provider for the evaluation and management of a patient. This code is used when the visit involves a high level of medical decision making or when the provider spends at least 75 minutes of total time on the encounter on a single date.

2. Official Description

The official description of CPT code 99223 is: ‘Initial 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, 75 minutes must be met or exceeded.’

3. Procedure

1. The healthcare provider performs an evaluation and management service for a patient in the inpatient hospital or observation setting.
2. The total time spent on the date of the encounter is at least 75 minutes or the level of medical decision making involved is high.
3. Total time includes both face-to-face and non-face-to-face activities on the encounter date.
4. Examples of activities that contribute to total time include reviewing tests, performing the exam or evaluation, counseling and educating the patient or caregiver, ordering tests, communicating with other healthcare providers, documenting the encounter, interpreting and communicating results, and coordinating care.
5. The provider determines the nature and extent of the history and/or exam appropriate for the encounter.

4. Qualifying circumstances

CPT 99223 is used for patients who require initial hospital inpatient or observation care. The visit must involve a high level of medical decision making or the provider must spend at least 75 minutes of total time on the encounter on a single date. The level of history and physical examination performed does not affect code selection.

5. When to use CPT code 99223

CPT code 99223 should be used when the healthcare provider provides initial hospital inpatient or observation care for the evaluation and management of a patient. This code should be used when the visit requires a medically appropriate history and/or examination and a high level of medical decision making. If the total time spent on the encounter on a single date is at least 75 minutes, CPT code 99223 can also be used.

6. Documentation requirements

To support a claim for CPT 99223, the healthcare provider must document the following information:

• Medically appropriate history and/or examination performed
• Total time spent on the encounter on a single date, which should be at least 75 minutes
• Activities performed during the encounter, such as reviewing tests, performing the exam or evaluation, counseling and educating the patient or caregiver, ordering tests, communicating with other healthcare providers, documenting the encounter, interpreting and communicating results, and coordinating care

7. Billing guidelines

When billing for CPT 99223, ensure that the visit meets the criteria for initial hospital inpatient or observation care and requires a medically appropriate history and/or examination. If the total time spent on the encounter on a single date is at least 75 minutes, CPT code 99223 can also be used. It is important to document all activities performed during the encounter to support the level of medical decision making or total time spent. CPT code 99223 should not be reported with other codes for services of 90 minutes or longer, as prolonged services code 99418 should be used instead.

8. Historical information

CPT 99223 was added to the Current Procedural Terminology system on January 1, 1992. There have been no updates to the code since its addition.

9. Similar codes to CPT 99223

Five similar codes to CPT 99223 include:

• CPT 99221: This code is used for initial hospital inpatient care for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and a low level of medical decision making.
• CPT 99222: This code is used for initial hospital inpatient care for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and a moderate level of medical decision making.
• CPT 99231: This code is used for subsequent hospital inpatient care for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and a straightforward level of medical decision making.
• CPT 99232: This code is used for subsequent hospital inpatient care for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and a low to moderate level of medical decision making.
• CPT 99233: This code is used for subsequent hospital inpatient care for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and a moderate to high level of medical decision making.

10. Examples

1. A healthcare provider spends 90 minutes on an initial hospital inpatient care visit, performing a comprehensive history and examination, reviewing tests, counseling and educating the patient, and coordinating care.
2. A healthcare provider spends 80 minutes on an initial observation care visit, performing a detailed history and examination, ordering tests, interpreting and communicating results, and coordinating care.
3. A healthcare provider spends 70 minutes on an initial hospital inpatient care visit, performing an expanded problem-focused history and examination, counseling and educating the patient, and documenting the encounter.
4. A healthcare provider spends 75 minutes on an initial observation care visit, performing a comprehensive history and examination, reviewing tests, counseling and educating the patient, and ordering tests.
5. A healthcare provider spends 85 minutes on an initial hospital inpatient care visit, performing a detailed history and examination, counseling and educating the patient, and coordinating care.
6. A healthcare provider spends 80 minutes on an initial observation care visit, performing an expanded problem-focused history and examination, ordering tests, interpreting and communicating results, and documenting the encounter.
7. A healthcare provider spends 95 minutes on an initial hospital inpatient care visit, performing a comprehensive history and examination, reviewing tests, counseling and educating the patient, and ordering tests.
8. A healthcare provider spends 70 minutes on an initial observation care visit, performing a detailed history and examination, counseling and educating the patient, and coordinating care.
9. A healthcare provider spends 75 minutes on an initial hospital inpatient care