Prepayment review for initial and subsequent hospital evaluation and management services CPT® codes 99223 and 99233

by | Nov 11, 2014 | CPT modifiers

First Coast Service Options Inc. (First Coast) recently conducted data analysis due to the high Comprehensive Error Rate Testing (CERT) error rates for evaluation and management services pertaining to Current Procedural Terminology® (CPT®) codes 99223 (initial hospital visit) and 99233 (subsequent hospital visit). The CERT November 2014 forecasting report indicates a projected error rate of 39.8 percent for CPT® code 99223 and a projected error rate of 34.4 percent for CPT code 99233. The data indicates that the specialty of internal medicine is the primary contributor to the CERT error rate: internal medicine error rates are currently trending at 36.6 percent for CPT® code 99233 and 33.3 percent for CPT® code 99223.

99223 – 70 minutes (average)

• Comprehensive history. Documentation needed:
• Chief complaint
• Extended history of present illness
• Complete review of systems
• Complete past, family, and social history
• Comprehensive examination. Documentation needed:
• General multi-system examination OR complete examination of a single organ system and other symptomatic or related body area(s)or eight or more organ system(s)
• Medical decision making that is of high complexity. Documentation needed (two of three below must be met or exceeded):
• Extensive number of diagnoses or management options
• Extensive amount and/or complexity of data to be reviewed
• High risk of significant complications, morbidity and/or mortality

Documentation requirements

The American Medical Association (AMA) CPT® manual defines code 99223 as follows:
Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components:

• A comprehensive history;
• A comprehensive examination; and
• Medical decision making of high complexity

Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the problem(s) requiring an admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient’s hospital unit.

The AMA CPT® manual defines code 99233 as follows:
Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components:

• A detailed interval history ;
• A detailed examination;
• Medical decision making of high complexity

Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family needs. Usually, the patient is unstable or has developed a significant new problem. Typically, 35 minutes are spent at the bedside and on the patient’s hospital unit.