Initial hospital care, per day, typically 50 minutes
Audit Defense & Denial Intelligence
Research-based denial patterns from OrbDoc Bill Analyzer
1. Insufficient documentation for moderate complexity
Very Common99222 requires moderate complexity medical decision-making for initial hospital care. This is the most commonly billed initial hospital code but also highly scrutinized. Denials occur when documentation doesn't demonstrate moderate MDM (must show 2 of 3: moderate number/complexity problems, moderate data review, moderate risk). Auditors look for multiple diagnoses, data reviewed, and risk level consistent with hospitalization.
Common Causes
- • Single diagnosis without comorbidities or complications documented
- • No evidence of data reviewed (labs, imaging, prior records)
- • Risk level not clearly moderate (could be managed outpatient or observation)
Resolution Strategy
Provider documents multiple problems addressed, data reviewed and incorporated, and moderate-to-high risk justifying hospital admission. Must clearly distinguish inpatient criteria from observation level care.
Relative Value Units (RVUs)
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Clinical Information
When to Use
Initial hospital admission with moderate complexity medical decision making
Common Scenarios
Documentation Requirements
- Comprehensive history and physical examination
- Moderate complexity medical decision making
- Multiple diagnoses or management options considered
- Review of moderate amount of data
Coding Guidelines
Common Modifiers
Bundling Rules
- Cannot be billed with subsequent hospital care codes on same date
- Includes all related services on admission date
- Superseded by critical care if criteria met
Exclusions
- 99234-99236 (observation or inpatient same date admission/discharge)
- 99291-99292 (critical care services)
- 99221, 99223 (different complexity levels)
Coding Notes
Clinical scenarios
- Comprehensive history and physical examination
- Moderate complexity medical decision making
- Multiple diagnoses or management options considered
- Comprehensive history and physical examination
- Moderate complexity medical decision making
- Multiple diagnoses or management options considered
- Comprehensive history and physical examination
- Moderate complexity medical decision making
- Multiple diagnoses or management options considered
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Frequently Asked Questions
CPT 99222 is the billing code for "Initial hospital care, per day, typically 50 minutes". Initial hospital admission with moderate complexity medical decision making
Medicare pays approximately $125.50 for CPT 99222 (national average). Actual payment varies by geographic location due to GPCI adjustments. Hospital and commercial insurance rates are typically 2-4x higher than Medicare rates.
CPT 99222 has a total RVU of 4.79, broken down as: Work RVU 2.99, Practice Expense RVU 1.58, and Malpractice RVU 0.22. RVUs (Relative Value Units) determine Medicare reimbursement rates.
The most common denial reason for CPT 99222 is "Insufficient documentation for moderate complexity". 99222 requires moderate complexity medical decision-making for initial hospital care. This is the most commonly billed initial hospital code but also highly scrutinized. Denials occur when documentation doesn't demonstrate moderate MDM (must show 2 of 3: moderate number/complexity problems, moderate data review, moderate risk). Auditors look for multiple diagnoses, data reviewed, and risk level consistent with hospitalization. Common causes include: Single diagnosis without comorbidities or complications documented; No evidence of data reviewed (labs, imaging, prior records). Appeal success rate is approximately 40-60%.
Key documentation requirements for CPT 99222 include: Comprehensive history and physical examination; Moderate complexity medical decision making; Multiple diagnoses or management options considered; Review of moderate amount of data. Missing or incomplete documentation is a leading cause of claim denials for this code.
Bundling considerations for CPT 99222: Cannot be billed with subsequent hospital care codes on same date. Includes all related services on admission date Use an NCCI bundling checker to verify specific code combinations before billing.
Common modifiers for CPT 99222 include: AI (Principal physician of record), 25 (Significant, separately identifiable E/M on same day as procedure). Modifiers indicate special circumstances and can affect reimbursement or prevent claim denials.
The typical time requirement for CPT 99222 is Typically 50 minutes of total time on date of encounter. Time-based codes require documentation of the actual time spent providing the service.