Initial Hospital Services Procedural Codes

Published 01/25/2021

For Medicare patients, inpatient consultations are now reported with the initial hospital visit CPT codes 99221–99223 (and not an emergency department [ED] visit code). Providers should consider the following two points in reporting these services.

First, CMS reminds providers that CPT code 99221 may be reported for an E/M service if the requirements for billing that code, which are greater than CPT consultation codes 99251 and 99252, are met by the service furnished to the patient. Second, CMS notes that subsequent hospital care CPT codes 99231 and 99232, respectively, require “a problem focused interval history” and “an expanded problem focused interval history” and could potentially meet the component work and medical necessity requirements to be reported for an E/M service that could be described by CPT consultation code 99251 or 99252.

When a patient is admitted to the hospital as an inpatient in the course of an encounter in another site of service (i.e., hospital, emergency department, observation status in a hospital, office, nursing facility), all E/M services provided by that physician in conjunction with that admission are considered part of the initial hospital care when performed on the same date as the admission.

Billing
Providers must bill the E/M code (other than a CPT consultation code) that describes the service they provide in order to be paid for the E/M service furnished. The general guideline is that the provider should report the most appropriate available code to bill Medicare for services that were previously billed using the CPT consultation codes. For services that could be described by inpatient consultation CPT codes, CMS has stated that providers may bill the initial hospital care service CPT codes and the initial nursing facility care CPT codes where those codes appropriately describe the level of service provided. When those codes do not apply, providers should bill the E/M code that most closely describes the service provided.

The inpatient care level of service reported by the admitting physician should include the services related to the admission he or she provided in the other sites of service as well as in the inpatient setting.

The code selection is based on level of service or time and is considered the first face-to-face service provided to an inpatient. The initial hospital codes (CPT codes 99221–99223) require that all three key components must be met (or exceeded).

Do not bill for other related E/M services on same date of admission. This is important to note when adding CPT modifiers 24 and 25 to the claim line.

CPT Modifier 24 is used when an unrelated E/M service occurred during a post-operative period of a major or minor surgical procedure (for codes with 10- or 90-day global period).

CPT Modifier 25 is used when a significantly, separately identifiable E/M service by the same physician on the same day of the procedure (for codes with 0 or 10-day global period). Different diagnoses are not required.

Initial Hospital Visit Codes
CPT code 99221 (30 minutes)

  • Describes the first inpatient encounter with the patient
  • Detailed or comprehensive history and exam
  • Straightforward or low-level medical decision-making

CPT code 99222 (50 minutes)

  • Comprehensive history and exam
  • Moderate-level medical decision-making

CPT code 99223 (70 minutes)

  • Comprehensive history and exam
  • High-level medical decision-making

Documentation
When coding from the medical record, only code those items clearly stated. Do not code anything listed as "possible," "probable," "maybe" or "suspected." Be as specific as possible and code acute conditions as "acute" and chronic conditions as "chronic." Be certain they are described as such in the chart. When a concise diagnosis cannot be made, code based on signs and symptoms. Signs and symptoms do not have to be separately listed if they are an integral part of the underlying diagnosis or condition already coded.

In situations where the minimum key component work and/or medical necessity requirements for initial hospital care (CPT codes 99221–99223) services are not met, subsequent hospital care CPT codes (99231 and 99232) could potentially meet requirements to be reported for the E/M service.

Reporting CPT code 99499 (unlisted evaluation and management service) should be limited to cases where there is no other specific E/M code payable by Medicare that describes that service. Reporting CPT code 99499 requires submission of medical records and contractor manual medical review of the service prior to payment. Reporting/billing under these circumstances are deemed to be unusual.

In the inpatient hospital setting, all physicians and qualified nonphysician practitioners (where permitted) who perform an initial evaluation visit may bill initial hospital care CPT codes (99221–99223) or nursing facility care CPT codes (99304–99306).

Documentation: Overview of Key Components
The key components of E/M including those services billed for initial hospital care are:

  1. History;
  2. Examination; and
  3. Medical decision-making

Note: When billing initial hospital care, all three key components must be fully documented in order to bill. When counseling and/or coordination of care dominates (more than 50 percent) the physician/patient and/or family encounter (at the bedside and floor/unit time in the hospital), then time may be considered the key or controlling factor to qualify for a particular level of E/M services. The extent of such time must be documented in the medical record.

Initial Hospital E/M Services (CPT® Codes 99221–99223) Documentation Requirements
99221 — 30 Minutes (average)
Detailed or comprehensive history — documentation needed:

  • Chief complaint
  • Extended history of present illness
  • Detailed — Extended review of systems; pertinent past, family and or social history
  • Comprehensive — Complete review of systems; complete past, family and social history

Detailed or comprehensive examination — documentation needed:

  • Detailed — Extended examination of the affected body area(s) or organ system(s) and any other symptomatic or related body area(s) or organ system(s)
  • Comprehensive — General multi-system examination OR complete examination of a single organ system and other symptomatic or related body area(s)or eight or more organ system(s)

Medical decision-making that is straightforward or of low complexity — documentation needed (two of three below must be met or exceeded):

  • Straightforward — Minimal number of diagnoses or management options; none or minimal amount and/or complexity of data to be reviewed; minimal risk of significant complications, morbidity and/or mortality
  • Low complexity — Limited number of diagnoses or management options; limited amount and/or complexity of data to be reviewed; low risk of significant complications, morbidity and/or mortality

99222 — 50 Minutes (average)
Comprehensive history — documentation needed:

  • Chief complaint
  • Extended history of present illness
  • Complete review of systems
  • Complete past, family, and social history

Comprehensive examination — documentation needed:

  • General multi-system examination OR complete examination of a single organ system and other symptomatic or related body area(s)or eight or more organ system(s)

Medical decision-making that is moderate complexity — documentation needed (two of three below must be met or exceeded):

  • Multiple number of diagnoses or management options
  • Moderate amount and/or complexity of data to be reviewed
  • Moderate risk of significant complications, morbidity and/or mortality

99223 — 70 Minutes (average)
Comprehensive history — documentation needed:

  • Chief complaint
  • Extended history of present illness
  • Complete review of systems
  • Complete past, family and social history

Comprehensive examination — documentation needed:

  • General multi-system examination or complete examination of a single organ system and other symptomatic or related body area(s) or eight or more organ system(s)

Medical decision-making that is of high complexity — documentation needed (two of three below must be met or exceeded):

  • Extensive number of diagnoses or management options
  • Extensive amount and/or complexity of data to be reviewed
  • High risk of significant complications, morbidity and/or mortality

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