CPT Code 99222: Initial Hospital Care, Moderate Complexity

What is initial hospital care, moderate complexity (CPT 99222)?

CPT 99222 is an evaluation and management service (E/M) code representing "initial hospital care, per day, for the evaluation and management of a patient." Based on Medicare billing and coding articles, this code requires these three key components: a comprehensive history, a comprehensive examination, and medical decision-making of moderate complexity.

This code is typically used by healthcare providers, specifically the admitting physician or principal physician of record, when first providing hospital inpatient or observation care services to a patient. The code applies to new or established patients admitted as hospital inpatients or placed in observation status requiring moderate medical decision making (MDM).

The initial hospital care codes, including accurate coding of 99222, represent the first hospital inpatient or observation encounter with a patient. These services may originate from various settings, including:

• Direct hospital admission from an office or other outpatient setting
• Hospital transfer from emergency department services
• Transfer from another facility or setting

CPT code 99222 documentation requirements

Accurate documentation forms the foundation for proper coding and billing. For CPT code 99222, documentation must support the three key components while meeting specific requirements for initial hospital care.

A comprehensive history for 99222 must include thorough documentation of:

• Chief complaint: A clear statement of the patient's primary reason for the hospital admission or encounter.
• Medically appropriate history of present illness (HPI): Documentation should capture at least four elements of the HPI or the status of at least three chronic conditions. Elements include location, quality, severity, duration, timing, context, modifying factors, and associated signs and symptoms.
• Review of systems (ROS): A comprehensive ROS includes documentation of at least 10 organ systems.
• Past, family, and social history (PFSH): All three areas must be documented: medical history, family history, and social history.

A comprehensive examination must include:

• General multi-system examination: Document findings from at least nine organ systems or body areas.
• Single specialty examination: Documentation meeting the requirements for a comprehensive single-specialty examination defined in specialty-specific guidelines.

All abnormal and relevant normal findings must be clearly documented, along with a description of the patient's general appearance and vital signs.

Medical decision making (MDM) for code 99222 must also demonstrate moderate complexity based on three factors:

• Number of diagnoses or management options: Documentation should show multiple diagnoses or management options, often with comorbidities requiring assessment.
• Amount and/or complexity of data: The record should demonstrate moderate complexity in data review, such as ordering and reviewing multiple tests, discussing findings with other providers, or reviewing old records.
• Risk of complications or morbidity/mortality: Documentation should establish moderate risk based on the presenting problems, diagnostic procedures ordered, and management options selected.

CPT code 99222 billing guidelines

Understanding billing guidelines for CPT code 99222 helps enhance the billing process and ensures appropriate reimbursement for services provided.

When determining whether CPT 99222 is appropriate for initial hospital care, all three key components must be met. Unlike some E/M services that require only two of the three key components, initial hospital care codes require that all three components (history, examination, and medical decision-making) meet or exceed the stated level.

While initial hospital care is typically component-based, time may be considered when:

• Counseling and/or coordination of care dominate the service: If more than 50% of the encounter involves counseling and/or care coordination, time may become the controlling factor.
• Prolonged services: Additional prolonged services codes may be applicable if face-to-face time significantly exceeds the typical time.

Several specific scenarios require special attention when billing CPT code 99222:

• Multiple same-day admissions: If a patient is admitted to observation status and then later admitted as an inpatient on the same day, only one initial service code should be reported.
• Transfer between services: When a patient transfers from one physician specialty to another during the same hospitalization, the receiving physician may report an initial hospital care code.
• Attending physician changes: If the attending physician changes during hospitalization, the new physician of record may report an initial hospital visit.

Other relevant codes

When working with initial hospital care services, several related CPT codes are important to understand:

• 99221: Initial hospital care, per day, requiring detailed history, detailed examination, and straightforward or low complexity medical decision making
• 99223: Initial hospital care, per day, requiring comprehensive history, comprehensive examination, and high complexity medical decision making
• 99234-99236: Observation or inpatient care services (including admission and discharge services) for patients admitted and discharged on the same date
• 99238-99239: Hospital discharge day management services
• 99217: Observation care discharge services
• 99306: High 50 minutes initial nursing facility care – new or established patient

These initial hospital inpatient, consultation codes, or observation care codes are essential to the medical decision-making process and proper coding practices. It also helps avoid billing errors.