2025 CPT code 99235
(Revised) Effective Date: N/A Revision Date: N/A Evaluation and Management - Hospital Inpatient and Observation Care Services 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 moderate level of medical decision making. When using total time on the date of the encounter for code selection, 70 minutes must be met or exceeded.
Modifiers may be applicable to further specify the circumstances of the service. Common modifiers for E/M services include modifier 25 (significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) and modifier 57 (decision for surgery).
Medical necessity for same-day admission and discharge must be clearly documented. The patient's condition must require hospital-level care, and the services provided must be appropriate for the diagnosis and treatment plan. The documentation should reflect the complexity of the patient's presentation and the intensity of the 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 the service is at least 70 minutes or the level of medical decision making (MDM) involved is moderate. 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 an admission encounter and discharge encounter on the same date. The E/M involves a moderate level of medical decision making or the provider spends at least 70 minutes of total time on the service on a single date.
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 moderate level of medical decision making. When using total time on the date of the encounter for code selection, 70 minutes must be met or exceeded.
Example 1: A patient is admitted to observation status for chest pain and shortness of breath. The physician spends 80 minutes evaluating the patient, reviewing test results, and coordinating care with cardiology. The patient is discharged the same day after the workup is negative for a cardiac event., A patient is admitted to inpatient status for a severe headache. The physician spends 75 minutes performing a history and physical exam, ordering and reviewing imaging studies, and making a diagnosis of migraine. The patient is treated and discharged the same day., A patient with a known history of asthma is admitted to observation status for an exacerbation. The physician spends 70 minutes stabilizing the patient, adjusting medications, and providing education on asthma management. The patient is discharged the same day after showing improvement.
Documentation should support the level of MDM or total time spent on the date of service. This includes details of the history and/or physical exam, if performed; diagnostic tests ordered and reviewed; treatment provided; and communication with other healthcare professionals. The documentation must support the medical necessity of the admission and discharge on the same date.
- Specialties:Internal Medicine, Family Medicine, Emergency Medicine, Pediatrics, Hospitalists
- Place of Service:Inpatient Hospital, Observation