2025 CPT code 99236
(Active) 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; evaluation and management, with admission and discharge on the same date; requiring high medical decision-making or at least 85 minutes of total time.
Modifiers may be applicable depending on the circumstances of the service. Consult the most current CPT modifier guidelines and payer-specific requirements.Examples of potentially applicable modifiers could include 25 (significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) or 57 (decision for surgery).
Medical necessity is established based on the complexity of the patient's case and the medical decision-making involved in their diagnosis and treatment. The documentation should clearly demonstrate the need for the comprehensive E/M service performed on the same day of admission and discharge.
The physician performs a comprehensive evaluation and management service, including admission and discharge encounters on the same date, requiring significant clinical judgment and time investment. This involves taking a history (if appropriate), performing an exam (if appropriate), ordering and reviewing tests, communicating with other healthcare providers, and coordinating care.
- Evaluation and Management
- Hospital Inpatient and Observation Care Services (Including Admission and Discharge Services)
In simple words: This code is used when a doctor sees a patient in the hospital as an inpatient or for observation, and the patient is admitted and discharged on the same day.The doctor's work is complex, requiring a lot of time (at least 85 minutes) or very difficult medical decisions.
This CPT code reports hospital inpatient or observation care services for evaluation and management (E/M), where admission and discharge occur on the same calendar date.The service necessitates a medically appropriate history and/or examination, and either a high level of medical decision-making (MDM) or a minimum of 85 minutes of total time spent on the service. Total time encompasses both face-to-face and non-face-to-face activities on the encounter date, such as reviewing tests, preparing for the visit, performing the exam, patient education, ordering tests, communication with other providers, documentation, interpreting results, and care coordination.The level of MDM is determined by the number and complexity of problems addressed, data review and analysis, and risk assessment.
Example 1: A 70-year-old patient presents to the emergency department with chest pain. After stabilization and initial workup, the patient is admitted as an inpatient for further evaluation. After additional testing (ECG, cardiac enzymes, echocardiogram), and consultation with cardiology, the patient is diagnosed with unstable angina and discharged the same day after receiving appropriate medications and education. Code 99236 would be appropriate if the total time spent on the case exceeds 85 minutes or MDM is high., A 55-year-old patient is admitted for an urgent surgical procedure (e.g., appendectomy). The procedure is performed, and the patient is discharged the same day.The preoperative assessment, intraoperative management, and postoperative care on the same day, meet the criteria of99236 if the total time exceeds 85 minutes or if MDM is high. , A 30-year-old patient is admitted to the observation unit after a motor vehicle accident with a head injury.The patient undergoes a detailed neurological examination, imaging (CT scan), and consultation with neurosurgery. The patient is discharged the same day after neurological assessment reveals no concerning findings.Code 99236 may be used if the total time of care is at least 85 minutes or if the MDM is high.
Comprehensive medical record documentation is required, including the details of the history (if obtained), physical exam (if performed), diagnostic and procedural findings, medical decision-making (including the number and complexity of problems addressed, the amount and complexity of data reviewed, and the risk of complications), the time spent in face-to-face and non-face-to-face encounters.The documentation should clearly justify the level of E/M service selected.If the code is used based on time, detailed documentation should support the total time claim.
** For services lasting 100 minutes or more, consider using prolonged services code 99418 in addition to 99236. Always ensure proper documentation to support the medical necessity and the level of service reported.
- Payment Status: Active
- Modifier TC rule: A Technical Component (TC) modifier is not applicable to this code.
- Specialties:Internal Medicine, Cardiology, Surgery, Emergency Medicine, Hospitalist Medicine
- Place of Service:Inpatient Hospital, Observation Unit