CPT Code 99223: Initial Hospital Care

What is CPT code 99223?

CPT code 99223 represents the highest level of initial hospital care for new or established patient evaluations. This code is used when a physician or qualified healthcare provider performs an initial hospital inpatient assessment requiring a comprehensive history, thorough physical examination, and medical decision-making of high complexity MDM. Coding guidelines refer to initial hospital care as the first encounter between a physician or qualified healthcare provider and a patient admitted to an inpatient or observation status in a hospital setting.

This code applies to a new or established patient receiving care in an inpatient setting under admission and discharge services. Initial hospital care codes replace consultations in the hospital inpatient setting. It's important to note that initial hospital care is distinct from hospital inpatient or observation care services, and subsequent hospital care codes are used for different phases of a patient's hospitalization.

The admitting physician or another provider from the same group practice can report this service on the same date as the admission, regardless of whether the patient came from the emergency department, nursing facility, or other service sites.

CPT code 99223 documentation requirements

The documentation requirements for CPT code 99223 are extensive and must clearly demonstrate the elements that justify this highest level of initial hospital inpatient care for appropriate reimbursement.

Required documentation elements

A comprehensive history must be established, including:

• Complete review of systems
• Detailed past medical history
• Relevant family history

A detailed physical examination must involve at least nine organ systems, detailed findings must be recorded, and high-complexity MDM (most critical component) must be performed, including documentation of multiple diagnoses, extensive data review, and significant risk factors affecting the patient's care.

Time-based reporting requirements

At least 75 minutes should be spent on the same date as the encounter. The documentation must include both face-to-face and non-face-to-face activities, and all activities must be directly related to the services provided.

CPT code 99223 billing guidelines

Proper medical billing for CPT code 99223 requires careful attention to specific guidelines that govern its use. This code can only be reported once per admission by the same physician or qualified provider from the same group practice.

Special circumstances

Use combination admission and discharge service codes (99234-99236) for same-day admissions and discharges. Also, do not use separate initial care and discharge services codes. Only one initial service should be reported for transitions from observation care to inpatient status.

Code selection considerations

The code's use is based on medical necessity and documented complexity, not just time spent. Documented elements must support the level of service, and failing to meet even one component could result in downcoding. Other insurance companies may also have their own specific requirements.

Billing practicalities

This code includes all services rendered on the admission date, and separate procedures should be billed with appropriate modifiers. This ensures appropriate reimbursement while avoiding duplication of payment for overhead costs.

Other relevant codes

Understanding how CPT code 99223 relates to other codes in the healthcare industry is essential for accurate billing and appropriate reimbursement. The following codes are commonly used in conjunction with or as alternatives to 99223, depending on the specific patient scenario and service context:

Initial hospital care codes include the following from 99221 to 99223:

• 99221: Initial hospital care, low-level medical decision making
• 99222: Initial hospital care, moderate-level medical decision making
• 99223: Initial hospital care, high complexity

Same-day admission and discharge include the following:

• 99234: Same-day admission/discharge, low complexity
• 99235: Same-day admission/discharge, moderate complexity
• 99236: Same-day admission/discharge, high complexity

Observation care services can also be relevant:

• 99218-99220: Initial observation care (by complexity level)
• 99217: Observation discharge day management
• 99224-99226: Subsequent observation care

Understanding discharge services can also be advantageous:

• 99238: Hospital discharge, 30 minutes or less
• 99239: Hospital discharge, more than 30 minutes