Subsequent hospital care, per day, typically 25 minutes
Audit Defense & Denial Intelligence
Research-based denial patterns from OrbDoc Bill Analyzer
1. Insufficient documentation for subsequent hospital visit
CommonSubsequent hospital care codes (99231-99233) require daily documentation of interval history, physical exam, and medical decision-making. 99231 is for straightforward/stable patients. Common denial: minimal or missing daily progress note, no documentation of patient status change or stability, copy-pasted notes without current assessment. Each subsequent day must show separate evaluation and management.
Common Causes
- • Progress note lacks interval history since previous day
- • No documentation of current clinical status or response to treatment
- • Physical exam not updated or marked 'unchanged from admission'
Resolution Strategy
Provider adds daily interval documentation: symptoms since last visit, clinical status changes or stability, exam findings, treatment adjustments or continuation rationale. Most payers accept appeals showing daily physician work.
💬 Plain Language Explanation
What this means
This is a hospital visit - a visit from your doctor while you were in the hospital. Your doctor checked on you and made simple medical decisions about your care.
Why you might see this
This is a common code for hospital visits. You might see this for routine daily visits from your doctor while you were hospitalized. This is the lowest level of hospital visit.
Common context
Used for routine daily hospital visits that require simple medical decision-making.
What to ask your provider
"'Was this a routine hospital visit, or were there additional concerns that might justify a higher-level code?'"
Relative Value Units (RVUs)
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Clinical Information
When to Use
Subsequent hospital care with straightforward or low complexity medical decision making
Common Scenarios
Documentation Requirements
- Problem-focused interval history
- Problem-focused examination
- Straightforward or low complexity medical decision making
- Update to treatment plan
Coding Guidelines
Common Modifiers
Bundling Rules
- Cannot be billed with other E/M codes same date by same physician
- Includes all visits on that date by same physician
- Cannot be billed on admission or discharge date
Exclusions
- 99221-99223 (initial hospital care codes)
- 99238-99239 (discharge day management)
- 99291-99292 (critical care services)
Coding Notes
Clinical scenarios
- Problem-focused interval history
- Problem-focused examination
- Straightforward or low complexity medical decision making
- Problem-focused interval history
- Problem-focused examination
- Straightforward or low complexity medical decision making
- Problem-focused interval history
- Problem-focused examination
- Straightforward or low complexity medical decision making
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Code Details
Medicare Pricing
PFSRVU Breakdown
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Frequently Asked Questions
CPT 99231 is the billing code for "Subsequent hospital care, per day, typically 25 minutes". Subsequent hospital care with straightforward or low complexity medical decision making
Medicare pays approximately $47.23 for CPT 99231 (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 99231 has a total RVU of 1.69, broken down as: Work RVU 1.05, Practice Expense RVU 0.56, and Malpractice RVU 0.08. RVUs (Relative Value Units) determine Medicare reimbursement rates.
The most common denial reason for CPT 99231 is "Insufficient documentation for subsequent hospital visit". Subsequent hospital care codes (99231-99233) require daily documentation of interval history, physical exam, and medical decision-making. 99231 is for straightforward/stable patients. Common denial: minimal or missing daily progress note, no documentation of patient status change or stability, copy-pasted notes without current assessment. Each subsequent day must show separate evaluation and management. Common causes include: Progress note lacks interval history since previous day; No documentation of current clinical status or response to treatment. Appeal success rate is approximately 70-80%.
Key documentation requirements for CPT 99231 include: Problem-focused interval history; Problem-focused examination; Straightforward or low complexity medical decision making; Update to treatment plan. Missing or incomplete documentation is a leading cause of claim denials for this code.
Bundling considerations for CPT 99231: Cannot be billed with other E/M codes same date by same physician. Includes all visits on that date by same physician Use an NCCI bundling checker to verify specific code combinations before billing.
Common modifiers for CPT 99231 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 99231 is Typically 25 minutes of total time on date of encounter. Time-based codes require documentation of the actual time spent providing the service.