Subsequent Hospital Visit : Coverage and Documentation Requirements


This Comparative Billing Report (CBR) focuses on physicians who submit claims for Subsequent Hospital Care Evaluation and Management (E/M) Services (CPT code 99231-99233). CBR information is one of the many tools used to assist individual providers to become proactive in addressing potential billing issues and performing internal audits to ensure compliance with Medicare guidelines.

For your personalized Subsequent Hospital Care (E/M) Services (CPT code 99231-99233) eCBR results Logon to eServices.

Subsequent Hospital Care E/M Services (CPT Codes):  Overview of Key Components
The key components of E/M including those services billed for Subsequent Hospital Care are:

  1. History
  2. Examination and
  3. Medical decision-making

Note: When billing subsequent hospital care, two of the three key components must be fully documented in order to bill. When counseling and/or coordination of care dominates (more than 50 percent) the physician/patient and/or family encounter (at the bedside and floor/unit time in the hospital), then time may be considered the key or controlling factor to qualify for a particular level of E/M services. The extent of such time must be documented in the medical record.

Subsequent Hospital Care (CPT 99231-99233) Documentation Requirements

 

CPT Code
Description
Problem Focused Examination
Documentation Requirements (two of three below must be met or exceeded)
99231
15 minutes
  • Problem focused interval history

Chief complaint

  • Brief history of present illness
 
Limited examination of the affected body area or organ system
(Based on either straightforward or low complexity) Minimal number of diagnoses or management options; None or minimal amount and/or complexity of data to be reviewed; Minimal risk of significant complications, morbidity and/or mortality or Limited number of diagnoses or management options; Limited amount and/or complexity of data to be reviewed; low risk of significant complications, morbidity and/or mortality
99232
25 minutes
  • Expanded problem focused interval history

Chief complaint

  • Brief history of present illness
  • Problem pertinent review of systems
Limited examination of the affected body area or organ system and any other symptomatic or related body area(s)or organ system(s)
  • Multiple number of diagnoses or management options
  • Moderate amount and/or complexity of data to be reviewed
  • Moderate risk of significant complications, morbidity and/or mortality
99233
35 minutes
  • Detailed interval history

Chief complaint

  • Extended history of present illness
  • Extended review of systems
  • Pertinent past, family and/or social history
Extended examination of the affected body area(s) or organ system(s) and any other symptomatic or related body area(s) or organ system(s)
Extensive number of diagnoses or management options
Extensive amount and/or complexity of data to be reviewed
High risk of significant complications, morbidity and/or mortality

Education Resources:
The Provider Outreach and Education (POE) team has published an educational video to address the issues pertinent to Subsequent Hospital Care CPT Codes. Your practice is being advised to view this video.

The Navigating the Components of Subsequent Hospital Care article is also a good resource.

Methods:
The metrics reviewed in this CBR are the proportion of billing for each HCPCS code in the grouping with comparisons done to peers within the state and jurisdiction. This report is an analysis of Medicare Part B claims extracted from the Palmetto GBA data warehouse. The analysis shows the portions of your Subsequent Hospital Care E/M family of codes (CPT codes 99231-99233) claims at each level compared to your peers in JM.

Example of eCBR Results from eServices:

eCBR Lookup Subsequent Hospital Care

 

 

Please be aware that the information contained within this CBR is not intended to be punitive or an indication of fraud. Rather, it is intended to be proactive communication that will assist you in identifying potential billing issues and help you with performing a self-audit of your conformity with Medicare guidelines.





Last Updated: 05/07/2021