2025 CPT code 99234
(Revised) Effective Date: N/A Revision Date: N/A Evaluation and Management - Hospital Inpatient and Observation Care Services Evaluation and Management Feed
Hospital inpatient or observation care, for the evaluation and management of a patient including admission and discharge on the same date, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded.
Modifiers may be applicable to further specify the circumstances of the service.Refer to current CPT guidelines for appropriate modifier usage.
Medical necessity must be established for the observation or inpatient admission and should be clearly documented in the medical record. This documentation should support the reason for the patient's admission and the intensity of services provided.
The provider performs an evaluation and management (E/M) service for a patient in the inpatient hospital or observation setting. This includes two or more encounters on the same date, with one being an initial admission encounter and another being a discharge encounter. The total time spent on the date of service must be at least 45 minutes or the level of medical decision making (MDM) involved is straightforward or low. Total time includes both face-to-face and non-face-to-face activities on the service date. Examples include, but are not limited to, reviewing tests and otherwise preparing for the patient visit, performing the exam or evaluation, counseling and educating the patient or caregiver, ordering tests, communicating with other healthcare providers, documenting the encounter, interpreting and communicating results, and coordinating care.
In simple words: The provider sees a patient for hospital inpatient or observation care, involving evaluation and management (E/M), with both admission and discharge happening on the same day. This involves a straightforward medical decision-making process or at least 45 minutes of the provider's total time spent on the same day. The 45 minutes include time spent with the patient and time spent on activities related to their care, even if not directly with the patient.
This code represents observation or inpatient hospital care for the evaluation and management of a patient, including both admission and discharge on the same date. It requires a medically appropriate history and/or examination, along with a straightforward or low level of medical decision making (MDM). Alternatively, the provider can select this code if the total time spent on the date of service is 45 minutes or more. The total time includes all activities related to the patient's care on that date, both face-to-face and non-face-to-face, such as reviewing tests, preparing for the visit, counseling, ordering tests, communicating with other healthcare providers, documenting the encounter, and coordinating care.
Example 1: A patient presents to the emergency department with chest pain and is admitted for observation. The physician spends 45 minutes evaluating the patient, reviewing test results, and determining the course of treatment. The patient is discharged the same day after observation and treatment., A patient with a known history of asthma presents to the emergency room with difficulty breathing. The provider admits the patient to observation for monitoring and treatment. After several hours of observation and treatment, which includes respiratory treatments and medication management, the patient's condition improves. The physician spends over an hour providing and coordinating care. The patient is discharged later the same day., A patient is admitted to inpatient care after a fall at home. The physician sees the patient for the initial evaluation and admission and then later returns to discharge the patient after tests and consultation with a physical therapist. All services occur on the same day.
Documentation should include detailed information about the patient's history, the examination performed, the medical decision making process (or total time spent), and the plan of care. All services performed should be documented appropriately in the medical record, including start and stop times for each activity if total time is used for code selection.
- Specialties:Internal Medicine, Family Medicine, Emergency Medicine and other specialties providing inpatient or observation care
- Place of Service:Inpatient Hospital, Observation Unit