CPT® Codes 99231, 99232, 99233
Codes 99231, 99232, and 99233 are used for the evaluation and management (E/M) of a patient, when a physician sees the patient in the hospital on an inpatient basis (follow up visit). These codes are based on the documentation and the guidelines for two out of the three key components and medical necessity that must be met to reach a level:
• To bill a 99231, be sure you meet two of the three components: problem-focused history, problem-focused exam, and straight forward or low medical decision-making (MDM); or based on time 15 minutes.
• To bill a 99232, be sure you meet two of the three components: expanded problem-focused history, expanded problem-focused exam, and moderate MDM; or based on time 25 minutes.
• To bill a 99233, be sure you meet two of the three components: a detailed history, detailed exam, and high MDM; or based on time 35 minutes.
The key point is the provider must document history, exam, and MDM and two out of those three must meet or exceed a level.
If the physician is billing based on time, there must be the correct time statement documented.
Remember: 99231-99233 are inpatient codes. If the patient is in observation status and not admitted to inpatient status, use outpatient consult codes (check your payer) or typical office visits such as 99201-99205 and 99211-99215. To help avoid denials and audits, be very observant of the codes you use when the patient is in different facilities.
Here is a good resource from the Centers for Medicare & Medicaid Services to better explain E/M service leveling: Evaluation and Management Services