Subsequent Hospital Care

CPT code 99233 (Subsequent Hospital Care), is used (per day) for the Evaluation and Management (E/M) of an established patient. Two of these three key components are necessary in order to bill this code:

• A detailed interval history
• A detailed examination
• Medical-decision making of high complexity

In order to receive credit for an interval history, the provider must document an update on the status of the patient from the last encounter. It may be a simple statement like "no complaint of shortness of breath," "complains of chest pain" or "patient doing well."

The extent of detailed examination performed and documented is dependent upon clinical judgment and the nature of the presenting problem(s). The examinations range from limited exams of single body areas to general multi-system or complete single-organ system exams. See Documentation Guidelines for E/M Services.

Medical Decision-Making
Medical decision-making consists of counseling and/or coordination of care with other physicians, other qualified health care professionals or agencies that provide components consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are spent at the bedside and on the patient’s hospital floor or unit.

If the level of service is reported based on counseling and/or coordination of care, the total length of time of the encounter should be documented and the record should describe/support in sufficient detail the nature of the counseling and/or activities to coordinate care.

Face-to-face time refers to the time with the physician only. Counseling by other staff is not considered to be part of the face-to-face physician/patient encounter time. Time spent by other staff is not considered in selecting the appropriate level of service.

If the physician is unable to obtain a history from the patient or other source, the record should describe the patient’s condition or other circumstance which precludes obtaining a history.

Comorbidities and other underlying diseases in and of themselves are not considered when selecting the E/M codes, unless their presence significantly increases the complexity of the medical decision making.

When counseling and/or coordination of care dominates more than 50 percent of the physician/patient and/or family encounter (face-to-face time in the office or other outpatient setting, floor/unit, time in the hospital, or nursing facility), time is considered the key or controlling factor to qualify for this particular level of E/M services. If the practitioner chooses to use time as the determining factor, documentation must be present. The documentation in the medical record must be of sufficient detail to justify the selection of the specific code used.

Resource: Evaluation and Management (E/M) Visits.