How Can You Tell When You Should Use CPT® Code 99233?


Find out How to Assign This High-Complexity Code with Confidence

U.S. physicians are billing for the services they provide during subsequent hospital care with higher CPT® codes than they used to. That’s the finding the HHS Office of Inspector General (OIG) released in a major 2012 study.

What’s driving this trend?

Yes, sometimes doctors wrongly assign higher codes. When reviewing claims submitted in 2015-2016, for instance, CMS found CPT® code 99233 was one of the evaluation and management (E/M) codes for which the agency most often improperly paid. Whether because of simple mistakes or fraudulent attempts to overcode, the documentation examined didn’t support this level of reimbursement. As a result, this code frequently catches auditors’ attention. Some practitioners shy away from it for just that reason.

But 99233, like other high-level CPT® codes, has its place—and changing demographics have made it more and more appropriate.

“Our patient population is increasingly complex,” observes MDCodePro founder Dr. Alexander Stemer. Today’s patients frequently suffer from multiple chronic conditions. More complex cases call for more complex medical decision-making (MDM), and more complex MDM calls for higher codes.

By using the MDCodePro app to master some basic principles about code 99233, and by keeping a few specific circumstances in mind, you can use this high complexity code, as well as all the others, accurately. And when you do, you’ll increase both your regulatory compliance and your revenue.


Reviewing the CPT® Code 99233 Description

Code 99233 description is the highest of the three CPT® codes designating subsequent hospital care.

cpt code 99233

Broadly speaking, as the Texas Medical Association clarifies:

  • Code 99231 identifies stable, recovering, or improving patients.
  • Code 99232 identifies patients with minor complications requiring active, continuous management, or patients who aren’t responding to treatment adequately.
  • Code 99233 identifies unstable patients, or patients with significant new complications or problems.

Unlike the codes for initial hospital care (code range 99221–99223), these subsequent care codes require only two of your note’s three key components be at the same level:

  • Interval history (what has happened to the patient between visits)
  • Physical examination (higher levels of which are reasonable during hospital stays)
  • MDM (the number and complexity of possible diagnoses you weigh, and the risk possible treatment options present to the patient)

What’s your practical takeaway?

If you’ve documented a high level of complexity/risk in your MDM, you need to document either the detailed history you took or the detailed examination you gave in order to correctly assign 99233 to the patient encounter.

When you follow MDCodePro best practices, you’ll document histories at the highest level and perform a comprehensive physical exam as part of every visit. (As you’ll discover in our video lectures, you’re routinely performing comprehensive physicals even if you’re not aware of it. The goal is to become aware and to document the work you’re already instinctively doing.)

So if you always perform and document the physical exam and history at the highest level, you can assign the optimal CPT® code of 99233 to any follow-up hospital visit during which you used MDM that had a high level of complexity/risk.


Three Specific Circumstances to Remember When Considering Code 99233

Mastering the “two of three” concept described above is an important factor in assigning code 99233 correctly.

Here are three more ways you can determine when this billing code is appropriate:

  • Verify the Complexity and Risk of Subsequent Hospital Care Visits. The average length of stay in U.S. hospitals ranges from 4.5 to 5.5 days — far shorter than they used to be. Unfortunately, financial pressures and other factors mean patients often stay in the hospital for less time than their complicated conditions warrant. Your visits with them will thus likely require complex MDM, because you must identify and treat more challenging conditions in a shorter span of time.
  • Consider Comorbidities and Other Complications. Document the patient’s condition accurately and fully, including comorbidities connected with the presenting problem. When you thoroughly document a patient’s relevant complications, you’re proving your highly complex MDM is necessary to treat the patient efficiently, and that the visit warrants the 99233 code.
  • Keep an Eye on the Clock. The MDCodePro approach doesn’t use duration of an encounter as a coding criterion. We stress complexity/risk as the basis for optimal coding instead. But CMS guidelines do recognize physicians’ face-to-face time spent counseling patients or coordinating care can make the difference in qualifying for a certain level of E/M services. During 99233 visits, a physician will typically spend 35 minutes or more with the patient and on the patient’s hospital floor or unit. In some cases, assuming you’ve met all other documentation requirements, you may be able to submit an optimal code of 99233 based on time—so don’t forget to keep one eye on the clock.


The Comprehensive Approach Is Also the Best Care

As a responsible and ethical physician, you’re never going to provide hospitalized patients more services than they reasonably need. And CPT® code 99233 isn’t what you should choose after a visit with an inpatient who’s rapidly improving and headed for discharge.

MDCodePro’s method of documenting and coding isn’t about doing more work than necessary. It is about making sure you get recognized and rewarded appropriately for the necessary work you do.

“Your comprehensive approach,” says Dr. Stemer, “is best care, and is rewarded in complexity/risk scoring.”

If the comprehensive care you provide and the complex MDM you use to provide it warrant any high-level CPT® code, why shouldn’t you claim the revenue your work is worth?

To find out more about how the innovative MDCodePro app can help you maximize all your documentation and coding, call us today at 219-301-7265, or request information through this convenient online form.

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