2025 CPT code 99231
(Revised) Effective Date: N/A Revision Date: N/A Evaluation and Management - Hospital Inpatient and Observation Care Services Feed
Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, 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, 25 minutes must be met or exceeded.
Modifiers may be applicable to this code, such as modifier 25 for a significant, separately identifiable E/M service.
The medical necessity must be documented and justified based on the patient's condition and the services provided.
The provider performs an evaluation and management (E/M) service for a patient in the inpatient hospital or observation setting. This is a subsequent service for the stay. The total time spent on the date of the encounter is at least 25 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 encounter date.
In simple words: The provider sees a patient for a follow-up visit in the hospital or observation setting. The visit involves a straightforward medical situation, or the provider spends at least 25 minutes with the patient on that day.
This code represents subsequent hospital inpatient or observation care. It involves a medically appropriate history and/or physical examination, when performed.The provider determines the nature and extent of the history and/or exam required. The extent of history and exam do not affect code selection. The code selection is based on medical decision making (MDM) or total time on the date of the encounter. This code requires straightforward or low MDM or at least 25 minutes of total time.
Example 1: A patient is admitted for pneumonia and is improving. The physician sees the patient for a follow-up visit, assesses their condition, and adjusts medications. The visit takes 25 minutes., A patient is in observation status for chest pain. The physician checks on the patient, reviews test results, and decides to discharge them. The total time spent is 30 minutes., A patient is hospitalized for a urinary tract infection. The physician performs a brief follow-up assessment and adjusts antibiotics. This visit is straightforward and takes 15 minutes, but documentation supports low MDM.
Documentation should support the level of MDM or the total time spent. This includes the medical history, examination findings, complexity of the problem(s) addressed, data reviewed, risk of complications, and plan of care.
- Revenue Code: M2B
- Specialties:Hospitalists, Internal Medicine, Family Medicine and various other specialties providing inpatient care
- Place of Service:Inpatient Hospital, Observation