In simple words: This code is used for a doctor's first visit to a patient in the hospital (either as an inpatient or under observation). The visit must involve either a straightforward medical decision or take at least 40 minutes.This includes time spent with the patient, reviewing tests, and planning the care.

This CPT code reports the first hospital inpatient or observation status encounter with the patient by the admitting physician.It represents initial hospital inpatient or observation care requiring a medically appropriate history and/or examination.Code selection is based on either the level of medical decision-making (MDM) or total time spent on the date of the encounter.For time-based selection, at least 40 minutes of total time (including face-to-face and non-face-to-face activities) must be documented. Straightforward or low MDM is also acceptable for code selection.The nature and extent of the history and/or exam are determined by the provider and documented appropriately; they do not affect code selection.A transition from observation status to inpatient does not constitute a new stay for the purpose of initial service reporting.For patients admitted and discharged on the same day, use codes 99234-99236.

Example 1: A 65-year-old male is admitted to the hospital for chest pain. The admitting physician spends 45 minutes evaluating the patient, reviewing EKG and cardiac enzyme results, discussing treatment options with the patient and family, and coordinating care with cardiology., A 72-year-old female is admitted to the hospital from the emergency department after a fall. The admitting physician spends 50 minutes reviewing the patient's history, performing a physical exam, ordering imaging studies, and discussing treatment plan with the patient and family. The patient has a straightforward medical condition and the physician's decision-making is straightforward., A 28-year-old female is admitted for postpartum hemorrhage. Although total time spent with the patient is less than 40 minutes, the complexity of her condition and the decision-making involved in managing her condition meets the requirements for straightforward medical decision making.The admitting physician’s actions require a high level of medical judgement and result in the management of a high risk condition.

Complete and accurate documentation is required including a detailed history of present illness, past medical history, family history, social history, review of systems, physical examination findings, assessment and plan, diagnostic and therapeutic orders. Total time must be documented if using time-based coding. If using MDM, all elements of MDM must be documented.

** This code is used only for the initial hospital visit.Subsequent visits are coded differently.This code may be used for patients located anywhere in the hospital, including dedicated observation units.