Hospital Inpatient and Observation Care Services
Let’s start this discussion with the Hospital Inpatient and Observation Care Services. As with everything else, there are a good deal of changes in this section. First, we’ll review the actual number changes and then guideline changes in this section.
Deleted Codes for Observation Services:
| Observation Care Discharge Services | (99217 has been deleted. To report observation care discharge services, see 99238, 99239) |
| Initial Observation Care | (99218, 99219, 99220 have been deleted. To report initial observation care, new or established patient, see 99221, 99222, 99223) |
| Subsequent Observation Care | (99224, 99225, 99226 have been deleted. To report subsequent observation care, see 99231, 99232, 99233) |
Guideline Changes: Hospital Inpatient and Observation Care Services
The following codes are used to report initial and subsequent evaluation and management services provided to hospital inpatients and to patients designated as hospital outpatient ‘observation status.’ Hospital inpatient or observation care codes are also used to report partial hospitalization services.
For patients designated/admitted as ‘observation status’ in a hospital, it is not necessary that the patient be located in an observation area designated by the hospital. If such an area does exist in a hospital, these codes may be utilized if the patient is placed in such an area.
For a patient admitted and discharged from hospital inpatient or observation status on the same date, report 99234, 99235, 99236, as appropriate.
Total time on the date of the encounter is by calendar date. When using MDM or total time for code selection, a continuous service that spans the transition of two calendar dates is a single service and is reported on one calendar date. If the service is continuous before and through midnight, all the time may be applied to the reported date of the service.
Initial Hospital Inpatient or Observation Care – New or Established Patient
The following codes are used to report the first hospital inpatient or observation status encounter with the patient.
An initial service may be reported when the patient has not received any professional services from the physician or other qualified health care professional or another physician or other qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice during the stay. When advanced practice nurses and physician assistants are working with physicians, they are consider as working in the exact same specialty and subspecialty as the physician.
When the patient is admitted to the hospital as an inpatient or to observation status in the course of an encounter in another site of the service (e.g., hospital emergency department, office, nursing facility), the services in the initial site may be separately reported. Modifier 25 may be added to the other evaluation and management service to indicate a significant, separately identifiable service by the same physician or other qualified health care professional was perform on the same date.
In the case when the services in a separate site are reported and the initial inpatient or observation care service is a consultation service, do not report 99221, 99222, 99223 99252, 99253, 99254, 99255. The consultant reports the subsequent hospital inpatient or observation care codes 99231, 99232, 99233 for the second service on the same date.
If a consultation is performed in anticipation of, or related to, an admission by another physician or other qualified health care professional, and then the same consultant performs an encounter once the patient is admitted by the other physician or other qualified health care professional, report the consultant’s inpatient encounter with the appropriate subsequent care code (99231, 99232, 99233). This instruction applies whether the consultation occurred on the date of the admission or a date previous to the admission. It also applies for consultations reported with any appropriate code.
For a patient admitted and discharged from hospital inpatient or observation status on the same date, report 99234, 99235, 99236, as appropriate.
For the purpose of reporting an initial hospital inpatient or observation care service, a transition from observation level to inpatient does not constitute a new stay.
| 99221 | Initial hospital inpatient or observation care, per day, for the evaluation and management of a patient, which require a medically appropriate history and/or examination and straightforward or low-level medical decision making When using total time – 40 minutes must be met or exceeded |
| 99222 | Initial hospital inpatient or observation care, per day . . . and moderate level of medical decision making. When using total time – 55 minutes must be met or exceeded |
| 99223 | Initial hospital inpatient or observation care, per day . . . and high level of medical decision making When using total time – 75 minutes must be met or exceeded |
| 99231 | Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which required a medically appropriate history and/or examination and straightforward or low-level of medical decision making. When using total time – 25 minutes must be met or exceeded |
| 99232 | Subsequent hospital inpatient or observation care, per day . . . and moderate level of medical decision making. When using total time – 35 minutes must be met or exceeded. |
| 99233 | Subsequent hospital inpatient or observation care, per day . . . and high level of medical decision making. When using total time – 50 minutes must be met or exceeded |
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References: 2023 CPT E/M descriptors and guidelines (ama-assn.org)