Prepayment review for CPT® codes 99232 and 99233 - Billing Example

CPT codes 99231-99233 are used to describe subsequent hospital care. These codes require documentation of the interval history at either problem focused, expanded problem focused, or detailed levels. The examination requires the same levels of documentation. The Medical decision making documentation must support straightforward, low, moderate, or high complexity. The nature of the presenting problem usually determines the levels of history and physical exam required.

1. CPT code 99231 usually requires documentation to support that the patient is stable, recovering, or improving.

2. CPT code 99232 usually requires documentation to support that the patient is responding inadequately to therapy or has developed a minor complication. Such minor complications might include careful monitoring of co-morbid conditions requiring continuous active management

3. CPT code 99233 usually requires documentation to support that the patient is unstable or has a significant new problem or complication.

Clinical examples of subsequent Hospital care codes are listed below. Please note that the examples were pulled from Appendix C of CPT 2004.


Clinical Example:

Coding of the visits during a six-day hospitalization of an eighty year old patient with a presumptive diagnosis of pneumococcal pneumonia and low oxygen saturation.

First day after the day of admission: The patient continues tachypnic with low oxygen saturation, and febrile. The patient is receiving oxygen and broad-spectrum antibiotics awaiting cultures results. At present there is an inadequate response and condition would appear to support the levels of history and Physical exam required for CPT
code 99232.

Second day after the day of admission: Less tachypnea, still febrile, still receiving oxygen and broad spectrum –antibiotics. Culture results isolate no specific pathogen and current antibiotics are continued. A continued inadequate response would appear to support the levels of history and Physical exam required for CPT code 99232.

Third day after day of admission: Patient is afebrile, room air oxygen saturation is good. Patient is obviously improved. Current antibiotics continued intravenously for one more day. The patient is recovering and improving. Condition would appear to support the levels of history and Physical exam required for CPT code 99231.

Fourth day after the day of admission: Afebrile with good room air oxygen saturation. IV antibiotics are discontinued and patient started on oral antibiotics. The patient is recovering and improving. Condition would appear to support the levels of history and Physical exam required for CPT code 99231.

Fifth day after day of admission: Patient is discharged and the appropriate discharge code is billed.


Admission Visit Daily Visit Consultation

Time (min) Code Time (min) Code Time (min) Code

30 99221 15 99231 20 99251 50 99222 25 99232 40 99252 70 99223 35 99233 55 99253  80 99254  110 99255


In situations where the minimum key component work and/or medical necessity requirements for initial hospital care services are not met, subsequent hospital care CPT codes (99231 and 99232) could potentially meet requirements to be reported for an E/M service that could be described by CPT consultation code 99251 or 99252. Contractors shall expect changes to physician billing practices accordingly. Medicare contractors shall not find fault with providers who report a subsequent hospital care code (99231 and 99232) in cases where the medical record appropriately demonstrates that the work and medical necessity requirements are met for reporting a subsequent hospital care code (under the level selected), even though the reported code is for the provider's first E/M service to the inpatient during the hospital stay.



Subsequent hospital care CPT codes 99231 and 99232, respectively, require “a problem focused interval history” and “an expanded problem focused interval history.” An E/M service that could be described by CPT consultation code 99251 or 99252 could potentially meet the component work and medical necessity requirements to report 99231 or 99232. Physicians may report a subsequent hospital care CPT code for services that were reported as CPT consultation codes (99241 – 99255) prior to January 1, 2010, where the medical record appropriately demonstrates that the work and medical necessity requirements are met for reporting a subsequent hospital care code (under the level selected), even though the reported code is for the provider's first E/M service to the inpatient during the hospital stay.
CPT code 99232 subsequent hospital care


Chief Complaint:

The Chief Complaint is a concise statement from the patient describing:

• The symptom • Problem • Condition • Diagnosis • Physician recommended return, or other factor that is the reason for the encounter

Review of Systems: 

An inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms which the patient may be experiencing or has experienced. For purpose of Review of Systems the following systems are recognized: • Constitutional (i.e., fever, weight loss) • Eyes • Ears, Nose, Mouth Throat • Cardiovascular • Respiratory • Gastrointestinal • Genitourinary • Musculoskeletal • Integumentary (skin and/or breast) • Neurologic • Psychiatric • Endocrine • Hematologic/Lymphatic • Allergic/Immunologic

Billing and Coding Guidelines.


Palmetto GBA focused on the Subsequent Hospital Care procedure range of 99231 through 99233.

When any level of subsequent hospital care is under review, the medical record should include results of diagnostic studies and changes to the patient’s status since the last assessment. Changes include history, physical condition and response to management.

An important step in strengthening the links in your processes is to coordinate with other physicians, qualified health care professionals, and/or agencies. This will help ensure the counseling and/or care provided is consistent with the nature of the problems and the family’s needs. Be certain to review the record with these questions in mind:

1. Is the history problem focused, expanded problem focused or a detailed interval history? Remember that an interval history is one that documents an update on the patient from the last encounter.

2. Is the exam a focused exam, which is CPT code 99231; an expanded problem focused exam, code 99232; or a detailed exam, code 99233?

3. Is the medical decision making straight forward or low complexity, code 99231; moderate complexity, code 99232; or high complexity, which would be code 99233?

4. How much time did the physician spend at the patient’s bedside? Time is a factor that  indicates the extent of the illness. This will guide you in selecting the correct CPT code.


The use of telehealth is limited in two ways: 

1. Subsequent hospital care services, with the limitation of one telehealth visit every 3 days (Common Procedural Terminology (CPT) codes 99231, 99232, and 99233); and 

2. Subsequent nursing facility care services, with the limitation of one telehealth visit every 30 days (CPT codes 99307, 99308, 99309, and 99310).


The Medicare physician fee schedule payment for surgical procedures includes all the services and visits that are part of the global surgery payment including when such surgical procedures may be fragmented. Subsequent Hospital Care visits (CPT codes 99231 – 99233) are not separately payable when included in the global surgery payment. The Hospital Discharge Day Management Service (CPT code 99238 or 99239) is a face-to-face evaluation and management (E/M) service with the patient and his/her attending physician. Physicians shall use the Observation or Inpatient Care Services (Including Admission and Discharge Services) using a code from CPT code range 99234 – 99236 for a hospital admission and discharge occurring on the same calendar date and when specific Medicare criteria, identified in §30.6.9.1, are met. The American Medical Association Current Procedural Terminology (CPT) codes 99238 and 99239 shall be paid only when they are performed face-to-face with the patient. Other physicians who manage the patient’s care (concurrent care) in addition to an attending physician, and who are not acting on behalf of the attending physician shall use the Subsequent Hospital Care codes from CPT code range CPT 99231 – 99233 for a final visit with the patient. Medicare includes payment for general paperwork through the pre-and post-service work of E/M services. The physician who personally performs a patient pronouncement of death shall bill for the face-to-face Hospital Discharge Day Management Service using CPT code 99238 or 99239. The date of death pronouncement shall reflect the calendar date of actual death pronouncement even if the paperwork is delayed to a subsequent calendar date.




Medicare Review on CPT 99232 AND 99233

The top services for First Coast Service Options Inc. (First Coast) with payment errors identified by Part  B comprehensive error rate testing (CERT) continue to be evaluation and management services. First Coast conducted a data analysis for Current Procedural Terminology® (CPT®) codes 99232 and 99233 (subsequent hospital care). The data indicates specialties internal medicine and cardiology are the primary contributors to the CERT error rate for subsequent hospital care services. Documentation requirements  the American Medical Association (AMA) CPT® manual defines code 99232 as  follows: Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components:

*** An expanded problem focused interval history ;

*** An expanded problem focused examination;

*** Medical decision making of moderate complexity Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family needs. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Typically, 25 minutes are spent at the bedside and on the patient’s hospital floor or unit.

The AMA CPT® manual defines code 99233 as follows: Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of
these three key components:

*** A detailed interval history ;

*** A detailed examination;

*** Medical decision making of high complexity Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family needs. Usually, the patient is unstable or has developed a significant new problem. Typically, 35 minutes are spent at the bedside and on the patient’s hospital floor or unit. First Coast and the Centers for Medicare & Medicaid Service (CMS) offer multiple resources addressing the documentation guidelines for E/M service levels at:

*** First Coast’s Evaluation and Management (E/M) services page, offering links to tools, FAQs, online learning, and additional resources.

*** CMS Internet-only manual (IOM) guidelines addressing multiple types and settings pertaining to E/M services.


First Coast actions

In response to the high percentage of error rates and the continual risks of improper payments associated with subsequent hospital care billed by internal medicine and cardiology specialists, First Coast will be implementing a prepayment medical review audit for CPT® codes 99232 and 99233 billed by cardiology; and CPT® codes 99232 billed by internal medicine specialty. The new audit will be based on a threshold of claims submitted for payment  by cardiology and internal medicine specialties in an effort to reduce the error rates for these hospital services. The audit will be implemented for claims processed on or after March 15, 2016.

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