Subsequent hospital visits account for one of the highest error categories for cardiologists in Ohio and West Virginia. A review of documentation by the Comprehensive Error Rate Testing (CERT) Documentation Contractor indicates ongoing problems with the medical record not supporting the submitted code for these visits.
Requirements for Subsequent Hospital Visits
- For each subsequent hospital visit CPT code, documentation must support at least two of the three key components of the service at the required level
- The three key components of Evaluation and Management (E/M) services are: History, Exam and Medical Decision Making
- You may use either the 1995 or 1997 E/M Documentation Guidelines in selecting the correct CPT code, but not both
- Subsequent hospital visits by cardiologists must meet the minimum requirements for the CPT code selected. If at least two of the three key components are not documented at the required level, select a lower level of service.
- The Medical Decision Making component is not the sole deciding factor in selecting the correct CPT code
- For patients whose condition improves throughout the hospital stay, the level of subsequent hospital visit required should decrease
- You may use time as the key or controlling factor in selecting the code for a subsequent hospital visit only if the visit consists predominantly of counseling or coordination of care. In other words, at least 50 percent of the time spent with the patient must be spent counseling or coordinating care in order to use time alone in selecting the CPT code.
Common Documentation and Coding Problems
- Subsequent hospital visits require only an interval history (e.g., history since the last encounter with the patient)
- If you are referring to a previous record of history, review of systems or other findings, note the date of the previous record in the notes for the current visit
- If you are asked to provide medical records in support of a subsequent hospital visit, review the notes carefully before submitting them to Palmetto GBA or another requesting Medicare contractor, such as the Comprehensive Error Rate Testing (CERT) Documentation Contractor. If the notes refer to a previous encounter, send both sets of notes to the requesting entity.
- If the patient is unable to provide a history or you are unable to perform an examination, note the reason in the medical record
The following table shows the requirements for each level of service for subsequent hospital visits:
| CPT Code | History (Interval) | Exam | Medical Decision Making | # of components required | Patient's condition | Usual time | Count time for: |
| 99231 |
Problem-focused |
Problem-focused |
Straightforward or low complexity |
2 of 3 |
Stable, recovering, or improving |
15 min. |
Bedside plus floor/unit time |
| 99232 |
Expanded problem-focused |
Expanded problem-focused |
Moderate complexity |
2 of 3 |
Responding inadequately to therapy or has developed minor complication |
25 min. |
Bedside plus floor unit time |
| 99233 |
Detailed |
Detailed |
High complexity |
2 of 3 |
Unstable, or has developed a significant complication or significant new problem |
35 min. |
Bedside plus floor/unit time |
Continuing Education
Palmetto GBA conducts periodic workshops on E/M Documentation and Coding Guidelines. Click below and access Workshops to find one near you:
- Go to Workshops
- Create a Login ID and register online
- Look for other handy resources on our Education Web page, under Workshop Handouts:
- Evaluation & Management Score Sheets
- Evaluation & Management Documentation Guidelines Educational Packet
- Hospital Evaluation & Management Services Educational Packet
Still have questions? Check out the CMS Educational Materials and Guidelines Web page for E/M Services