Subsequent hospital care, per day, typically 50 minutes
Audit Defense & Denial Intelligence
Research-based denial patterns from OrbDoc Bill Analyzer
1. Insufficient documentation for high complexity follow-up
Common99233 is highest subsequent hospital code (high complexity). Reserved for unstable patients or days with significant changes requiring high-level decision-making. Commonly denied when billed for moderately complex or routine days. Requires documentation of high MDM: multiple new problems, deteriorating status, complex medication adjustments, extensive data interpretation, or high risk requiring intensive monitoring.
Common Causes
- • High complexity not supported - should be 99232 or 99231
- • Patient clinically stable without acute changes
- • Extensive data not documented or not complex
Resolution Strategy
Provider documents high-complexity day: clinical deterioration, new complications, extensive test interpretation, complex treatment decisions, ICU consideration. May need to accept appropriate lower code for stable days.
💬 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 complex medical decisions about your care.
Why you might see this
This is a common code for hospital visits. You might see this for daily visits from your doctor while you were hospitalized that required complex medical decision-making, such as for serious conditions or complications.
Common context
Used for hospital visits that require complex medical decision-making, often for serious conditions or complications.
What to ask your provider
"'What made this hospital visit complex? What medical decisions were made?'"
Relative Value Units (RVUs)
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Clinical Information
When to Use
Subsequent hospital care with high complexity medical decision making
Common Scenarios
Documentation Requirements
- Comprehensive interval history
- Comprehensive examination
- High complexity medical decision making
- Extensive revision of treatment plan with detailed rationale
Coding Guidelines
Common Modifiers
Bundling Rules
- Cannot be billed with other E/M codes same date by same physician
- May transition to critical care if criteria met
- Cannot be billed on admission or discharge date
Exclusions
- 99291-99292 (critical care services)
- 99221-99223 (initial hospital care codes)
- 99238-99239 (discharge day management)
Coding Notes
Clinical scenarios
- Comprehensive interval history
- Comprehensive examination
- High complexity medical decision making
- Comprehensive interval history
- Comprehensive examination
- High complexity medical decision making
- Comprehensive interval history
- Comprehensive examination
- High complexity medical decision making
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Code Details
Medicare Pricing
PFSRVU Breakdown
OPPS Details
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Frequently Asked Questions
CPT 99233 is the billing code for "Subsequent hospital care, per day, typically 50 minutes". Subsequent hospital care with high complexity medical decision making
Medicare pays approximately $113.86 for CPT 99233 (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 99233 has a total RVU of 3.97, broken down as: Work RVU 2.48, Practice Expense RVU 1.31, and Malpractice RVU 0.18. RVUs (Relative Value Units) determine Medicare reimbursement rates.
The most common denial reason for CPT 99233 is "Insufficient documentation for high complexity follow-up". 99233 is highest subsequent hospital code (high complexity). Reserved for unstable patients or days with significant changes requiring high-level decision-making. Commonly denied when billed for moderately complex or routine days. Requires documentation of high MDM: multiple new problems, deteriorating status, complex medication adjustments, extensive data interpretation, or high risk requiring intensive monitoring. Common causes include: High complexity not supported - should be 99232 or 99231; Patient clinically stable without acute changes. Appeal success rate is approximately 40-60%.
Key documentation requirements for CPT 99233 include: Comprehensive interval history; Comprehensive examination; High complexity medical decision making; Extensive revision of treatment plan with detailed rationale. Missing or incomplete documentation is a leading cause of claim denials for this code.
Bundling considerations for CPT 99233: Cannot be billed with other E/M codes same date by same physician. May transition to critical care if criteria met Use an NCCI bundling checker to verify specific code combinations before billing.
Common modifiers for CPT 99233 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 99233 is Typically 50 minutes of total time on date of encounter. Time-based codes require documentation of the actual time spent providing the service.