2025 CPT code 99223
(Active) Effective Date: N/A Revision Date: N/A Evaluation and Management - Initial Hospital Inpatient or Observation Care Evaluation and Management Feed
Initial hospital inpatient or observation care involving high-level medical decision-making or at least 75 minutes of total time.
Modifiers 25 (significant, separately identifiable E/M service on the same day) may be appropriate in certain scenarios.Other modifiers may be used as clinically indicated and per payer requirements.
Medical necessity for initial inpatient or observation care must be clearly documented. This means the patient's condition necessitates the level of care and resources available in an inpatient setting.
The physician performs a comprehensive evaluation and management service for an inpatient or observation patient.This involves history-taking (if appropriate), physical examination (if appropriate), ordering and reviewing tests, communicating with other healthcare professionals, developing a treatment plan, and coordinating care.The level of MDM is high, or the total time spent is at least 75 minutes.
- Evaluation and Management
- Evaluation and Management > Hospital Inpatient and Observation Care Services > Initial Hospital Inpatient or Observation Care
In simple words: This code is for a doctor's first visit to a patient in the hospital (inpatient or observation status).The visit is complex, requiring a lot of the doctor's time (at least 75 minutes total) or involving very complicated medical decisions.
CPT code 99223 represents initial hospital inpatient or observation care for a patient requiring a medically appropriate history and/or examination and a high level of medical decision-making (MDM).The total time spent on the date of the encounter must be at least 75 minutes. This includes face-to-face and non-face-to-face time such as reviewing tests, preparing for the visit, performing the exam, counseling, ordering tests, communicating with other providers, documenting, interpreting results, and care coordination.MDM considers the number and complexity of problems, data reviewed, and risk of complications.
Example 1: A 72-year-old male admitted with acute myocardial infarction (AMI) requiring extensive cardiac monitoring, multiple medications, and consultations with cardiology and critical care. The initial assessment and management takes 90 minutes., A 28-year-old female admitted after a motor vehicle accident with multiple injuries, requiring multiple imaging studies, fracture reduction, pain management, and orthopedic consultation. The initial assessment requires high MDM and total time exceeds 75 minutes., A 65-year-old female admitted with acute exacerbation of chronic obstructive pulmonary disease (COPD), requiring respiratory support, IV antibiotics, and close monitoring. The initial encounter with comprehensive assessment and management plan takes at least 75 minutes.
Detailed documentation of the history (including pertinent negatives if appropriate), physical examination (including pertinent negatives if appropriate), diagnostic and therapeutic interventions, level of MDM (including the number and complexity of problems, data reviewed, and risk), and total time spent on the date of the encounter.Complete medical record should support medical necessity for admission and the level of care provided.
** Accurate coding requires thorough documentation of all aspects of the encounter, including time spent and MDM level.Pay close attention to the total time requirement (75 minutes).For prolonged services of 90 minutes or more, consider also using CPT code 99418.
- Revenue Code: M2A (Hospital Visit - Initial)
- Payment Status: Active
- Modifier TC rule: Not applicable.
- Specialties:Internal Medicine, Cardiology, Surgery, Emergency Medicine, Hospitalist, Critical Care
- Place of Service:Inpatient Hospital, Observation