What CPT codes are used for inpatient progress notes?

Subsequent hospital care uses 99231-99233 based on MDM complexity. 99231: straightforward or low complexity (stable patient, minor adjustments). 99232: moderate complexity (responding to treatment, one condition worsening). 99233: high complexity (unstable, requiring significant management changes). Select based on the highest level of MDM supported by documentation, not patient acuity alone.

How do I document medical necessity for daily hospital visits?

Document specific reasons daily visits are needed: active treatment adjustments, monitoring for complications, unstable vital signs, pending test results affecting management, complex discharge planning, patient/family communication needs. If the patient is stable and awaiting discharge, documentation should reflect reduced visit frequency or justify continued daily care.

What documentation supports 99233 for a hospitalist progress note?

99233 requires high complexity MDM: 1+ acute/chronic illness with severe exacerbation or life threat, extensive data review, AND high-risk management decisions (drug therapy requiring intensive monitoring, decision for procedure, escalation of care). Document the specific high-risk elements: 'Patient with septic shock requiring vasopressor titration and invasive monitoring.'

How should overnight events be documented in progress notes?

Document: significant vital sign changes, new symptoms reported to nursing, medication changes made overnight, nursing concerns, any rapid response or code events, and consultant recommendations received. This demonstrates continuity of care and supports the clinical decision-making documented in the assessment and plan.

What discharge planning documentation is required in progress notes?

Document: anticipated discharge date, barriers to discharge (medical stability, social, equipment needs), discharge disposition (home, SNF, rehab, LTACH), services arranged (home health, DME, follow-up appointments), patient/family education provided, and medication reconciliation status. Early discharge planning documentation supports appropriate length of stay and reduces denials.

Hospitalist Progress Note Template - Inpatient Daily Note

Internal Medicine — Hospitalist Progress Note Template

Internal Medicine Hospital Medicine Updated: 11/7/2025

The Hospitalist Progress Note Template is designed for hospitalists and internal medicine physicians documenting daily inpatient progress notes. This template efficiently documents the hospital course, daily assessment, treatment plan adjustments, and discharge planning while maintaining compliance with documentation requirements. The template supports appropriate billing for hospital visits (CPT 99231-99233) and includes sections for overnight events and changes, subjective assessment from patient and nursing, focused physical examination, review of laboratory and imaging results, assessment of each active problem with clinical reasoning, updated treatment plan for each problem, discharge planning updates, and plan for next 24 hours. This template ensures thorough daily documentation, supports care coordination, facilitates discharge planning, and maintains documentation efficiency for high-volume hospitalist practices. Ideal for hospitalist programs, internal medicine services, academic medical centers, and community hospitals managing daily inpatient documentation.

Progress Note

Date: [Date]
Day [X] of hospitalization

Overnight Events

[Significant overnight events, nursing concerns, vital sign changes]

Subjective

Patient reports: [Current symptoms, concerns, response to treatment]
Pain: [Level if applicable]
Functional status: [Activity level, mobility]

Objective

Vital signs: BP, HR, RR, Temp, SpO2, I/O
Physical examination (focused):

General: [Appearance, alertness]
Cardiovascular: [Heart rate, rhythm, murmurs, pulses, edema]
Respiratory: [Rate, effort, breath sounds]
Abdomen: [Soft, distended, bowel sounds, tenderness]
Extremities: [Edema, pulses]
Other: [Relevant findings]

Laboratory/Imaging

[Review of new or significant results]

Assessment

1) [Problem 1] — Status: [Improved / Stable / Worsened]

Clinical reasoning: [Brief assessment]

2) [Problem 2] — Status: [As applicable]
3) [Other active problems]

Plan

For each problem:
1) [Problem 1]:

Continue / Adjust medications: [specify]
Diagnostics: [Labs, imaging if needed]
Monitoring: [Vital signs, I/O, etc.]
Consultations: [If needed]

2) [Problem 2]: [As applicable]
3) Discharge planning: [Status, barriers, anticipated discharge date]

Next 24 Hours

[Key monitoring, interventions, or decisions needed]

Internal Medicine — Hospitalist Progress Note Template

Template