Subsequent Hospital Visit: Coverage and Documentation Requirements

Published 06/27/2019

This electronic Comparative Billing Report (eCBR) focuses on physicians who submit claims for Subsequent Hospital Care Evaluation and Management (E/M) Services (CPT code 99231-99233). eCBR information is one of the many tools used to assist individual providers in becoming proactive in addressing potential billing issues and performing internal audits to ensure compliance with Medicare coverage guidelines.

For your personalized eCBR results on Subsequent Hospital Care (E/M) Services (CPT code 99231-99233), log into our eServices portal. An eCBR will be available for providers who have at least 10 claims in history for this CPT code family during the time period selected.

Subsequent Hospital Care (CPT 99231-99233) Documentation Requirements

CPT Code
Documentation Requirements
• Typically 15 minutes
• Usually the patient is stable, recovering or improving
Requires two of the three key components:
• A problem focused interval history
• A problem focused examination
• Straightforward or low-complexity medical decision making
• Typically 25 minutes
• Usually the patient is responding inadequately to therapy or has developed a minor complication  
Requires two of the three key components:
• An expanded problem focused interval history
• An expanded problem focused examination
• Moderate complexity medical decision making
• Typically 35 minutes
• Usually the patient is unstable or has developed a significant complication or a new problem
Requires two of the three key components:
• A detailed history
• A detailed examination
• High complexity medical decision making

Note: When billing subsequent hospital care, two of the three key components must be fully documented at the level required by the CPT description in order to meet the code requirements.

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. 

If the physician elects to report the level of service based on counseling and/or coordination of care, the total length of time of the encounter (face-to-face or floor time, as appropriate) should be documented. The provider should include a note that more than 50 percent of the time was spent in counseling and/or coordination of care. The record should describe the counseling and/or activities performed in coordinating care.

The metrics reviewed in this eCBR are the proportion of billing for each CPT code in the grouping with comparisons done to peers within the state and jurisdiction. This report is an analysis of Medicare Part B claims extracted from the Palmetto GBA Railroad Medicare data warehouse. The analysis shows the portions of your Subsequent Hospital Care E/M family of codes (CPT codes 99231-99233) claims at each level compared to your peers in your state and in the RRB SMAC.

Example of eCBR Results from eServices

Please be aware that the information contained within this eCBR is not intended to be punitive or an indication of fraud. Rather, it is intended to be proactive communication that will assist you in identifying potential billing issues and help you with performing a self-audit of your conformity with Medicare guidelines.

For more information about this or other eCBRs, please call our Provider Contact Center at 888-355-9165, and select Option 5. Customer Service Representatives are available Monday through Friday, from 8:30 a.m. - 4:30 p.m. in all time zones with the exception of Pacific Time. This service is available from 8:30 a.m. - 4 p.m. PT.

Educational Resources

CMS Resources

Palmetto GBA Railroad Medicare Resources

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