99223, 99220, 99236 CPT® Code Descriptions, Progress Note, RVU, Distribution.

This 99223, 99220 and 99236 CPT® lecture reviews the procedure code definitions, national distribution data, RVU values and progress note requirements for the high level initial hospital service encounter. CPT stands for Current Procedural Terminology.  I have chosen to discuss these three codes together because their medical billing and coding guidelines are identical with regards to determining the level of service provided.  What is the difference between these three initial hospital encounter codes?  CPT® 99223 is the highest (level 3) initial inpatient H&P encounter code.  CPT® 99220 is the highest (level 3) initial observation H&P encounter code used only by the attending physician or non-physician practitioner (NPP).  CPT® 99236 is the highest (level 3) admit/discharge same day bundled encounter code used only by the attending physician or NPP.  CPT® 99236 can be used in both inpatient and observation same day admit and discharge scenarios.


All three of these initial hospital encounter codes represent the highest level of service under the Healthcare Common Procedure Coding System (HCPCS) for initial inpatient, observation and admit and discharge same day bundled hospital encounters.  Before physicians and NPPs can choose the right level of CPT® service (low, medium or high), they must first understand which  group of CPT® codes apply in their initial hospital service encounter  (inpatient, observation, same/day admit and discharge, critical care).   For readers who need further help in determining the correct group of codes to consider for their admission, I refer them to my post on initial hospital admission codes.  Here, I guide the physician and other NPPs  through a series of questions that will help them determine which set of initial hospital encounter codes apply to their patient's situation.  This process can become quite complex.  Understand it well before proceeding with this coding lecture.  Once the correct group of codes are determined, the practitioner can determine the correct level of service.  The rest of this lecture describes the the level 3 (highest)  initial hospital encounter codes 99223, 99220 and the bundled admit and discharge same day code 99236.

The low level admission for inpatient, observation and same day admit and discharge hospital codes (99221, 99218 and 99234 respectively) and the mid level admission for inpatient, observation and same day admit and discharge hospital codes (99222, 99219 and 99235 respectively) are described elsewhere on The Happy Hospitalist as part of my complete collection of CPT® lectures.  I have also provided a detailed comparison of a level 2 vs. level 3 H&P for side-by-side comparison.  I am a board certified internist and hospitalist with over ten years of clinical experience in a community hospitalist program providing physician services at a large regional hospital system. I have written an extensive collection of evaluation and management (E/M) lectures over the years to help physicians and NPPs (nurse practitioners, physician assistants, clinical nurse specialists and certified nurse midwives) understand the complex world of hospital and clinic based evaluation and management coding requirements. Some of these lectures were written several years ago, but their information remains highly relevant today.

Once  the correct grouping of codes has been determined,  the correct CPT® level of service that documentation supports should be defined.  The rest of this coding lecture details the requirements for the highest level initial encounter codes.  For the purposes of simplicity, the billing requirements for 99223 = 99220 = 99236.  The billing requirements for 99222 = 99219 = 99235.  The billing requirements for 99221 = 99218 = 99234.  This is why I have chosen to bundle these three initial hospital CPT® evaluation codes together for discussion. 

My collection of lectures and accompanying coding resources are used by myself to make sure I stay compliant with the rules and regulations of the CMS. All CPT® lectures I have written are organized in one easy-to-find location.  As you are learning to understand CPT® E/M coding, always remember that it is your responsibility to make sure your documentation supports your level of service you are submitting for reimbursement. How much you write in the chart should not be used to determine your level of service. What matters most are the details of your documentation as defined by the rules discussed in this and other CPT® lectures. The CMS E/M services guide referenced below says the care you provide must be "reasonable and necessary". In addition, all progress notes must be dated and have a legible signature or proof of signature attestation.

99223, 99220, 99236 CODE DESCRIPTIONS

My interpretations detailed below are based on my review of the 1995 and 1997 E&M guidelines, the CMS E&M guide and the Marshfield Clinic audit point system for medical decision making. These resources can be found in my hospitalist resources section linked here. The Marshfield Clinic point system is voluntary for Medicare carriers but has become the standard compliance audit tool in many parts of the country. You should check with your own Medicare carrier in your state to verify whether or not they use a different standard than that than that which I have presented here in my free educational discussion. I recommend all readers obtain their own up-to-date CPT® reference book as the definitive authority on CPT® coding. I have provided access to Amazon through the 2018 CPT® standard edition pictured to the right. These three CPT® codes can be used by any qualified healthcare practitioner to get paid for their hospital initial care evaluations.  How does the AMA define codes 99223, 99220 and 99236?

CPT® 99223 is defined by the AMA as:
Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components:  a comprehensive history; a comprehensive examination; and medical decision making of high complexity.  Counseling and/or coordination of care with other providers 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 admission are of high severity.  Physicians typically spend 70 minutes at the bedside and on the patient's hospital floor or unit
CPT® 99220 is defined by the AMA as:
Initial observation care, per day, for the evaluation and management of a patient, which requires these three key components:  a comprehensive history; a comprehensive examination; and medical decision making of high complexity.  Counseling an/or coordination of care with other providers 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 admission to "observations status" are of high severity.  Physicians typically spend 70 minutes at the bedside and on the patient's hospital floor or unit.  
CPT® 99236 is defined by the AMA as:
Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date which requires these three key components:  a comprehensive history; a comprehensive examination; and medical decision making of high complexity.  Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.   Usually the presenting problem(s) requiring admission are of high severity.  Physicians typically spend 55 minutes at the bedside and on the patient's hospital floor or unit.  
As you can see, the requirements for  CPT® 99223, 99220 and 99236 are equal, except for the typical time on  99236 of 55 minutes compared with 70 minutes for the other two CPT® codes.  That's why these three codes can be grouped together when discussing the E/M guidelines we have been given to stay compliant with CMS rules and regulations.  These codes can be billed based on time under certain circumstances. I have detailed those discussions elsewhere. Documentation of time is not a required component to stay  compliant with CMS rules. If billed without time as a consideration, these three codes should be billed based on the documentation rules detailed in the 1995 or 1997 guidelines referenced above. The three relevant components to a hospital initial care note are the:
  1. History
  2. Physical Examination
  3. Medical Decision Making Complexity (MDM)  
For all initial hospital encounter evaluations, the highest documented three out of three for history, physical and MDM determines the correct service code. Compare this with the highest documented two out of three components being required for hospital subsequent care encounters. Again,  the level of service for all three groupings of initial hospital encounters from 99221-99223, 99218-99220 and 99234-99236 are determined by the highest  three out of three components from history, physical and MDM.  That means the level of service is determined by the lowest level of documentation from any of the three areas.  If your history and MDM meet criteria for a level three admit, but your physical exam only meets criteria for a level 1 H&P, you have provided the lowest documented level of service.  Notice I said documented and not performed.  If you don't document your work, it's considered not done.  Documentation is key to staying compliant.   The following discussion details the absolute minimum requirements required to remain compliant with CPT® codes 99223, 99220 and 99236. In addition, remember a face-to-face encounter is always required.
  • Comprehensive history
    • Requires 4 elements from the history of present illness (HPI) OR documentation of the status of three chronic or inactive medical conditions.   HPI elements are location, quality, severity, duration, timing, context, modifying factors and associated signs and symptoms.
    • Requires  documentation from 10+ review of systems.  ROS is an inventory of body systems.  The E/M rules recognize the following systems for ROS purposes:  constitutional symptoms, eyes, ears/nose/mouth/throat, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, integumentary (skin and or breast), neurological, psychiatric, endocrine, hematologic/lymphatic and allergic/immunologic.  Those systems with positive or pertinent negative responses must be individually documented.  For the rest of the systems, documentation that all other systems are negative is permissible. 
    • Requires documentation from  past medical history (illnesses, operations, injuries and treatments) and family history and social history (PFSH).
  • Comprehensive physical exam:
    • 1995 guidelines: A general multi-system examination or complete examination of a single organ system. The medical record for a general multi-system examination should include findings from about 8 or more of the 12 organ systems.
    • 1997 guidelines: A general multi-system examination, or complete examination of a single organ system and other symptomatic or related body area(s) or organ system(s).  It should include at least nine organ systems or body areas with 2 bullets in each section.  Physical exam is complex for E/M This process is thoroughly detailed in the CMS E/M reference guide (pages 29-30 for the 1995 guidelines and pages 47 and beyond for the 1997 guidelines)
    • Note the wordage difference with body area vs organ systems. They are not the same. This stuff is complex.  A review of the acceptable body areas and organ systems can be found in that CMS E&M reference guide on pages 29 and 30.  The recognized body areas are head (including face), neck, chest (including breasts and axillae), abdomen, genitalia (including groin and buttocks), back (including spine) and each extremity. The recognized organ systems are constitutional (including vital signs and general appearance), eyes, ears/nose/mouth/throat, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, skin, neurological, psychiatric, hematologic/lymphatic/immunologic.
  •  Medical decision making of high complexity (MDM): This is split into three components. The highest 2 out of the 3 levels in MDM are used to determine the overall level of MDM. The level is determined by a complex system of points and risk. What are the three components of MDM and the minimum required level of points and risk as defined by the Marshfield Clinic audit tool?
    • Diagnosis (4 points) 
    • Data (4 points) 
    • Risk (high) The table of risk can be found on page 35 of the CMS E/M reference guide.
The medical decision making point system is quite complex. I have a detailed reference to it on my E/M pocket cards described below. These cards help me understand everyday what type of care my documentation supports. I carry these cards with me at all times and reference them all day long. They help me understand what level of service my evaluation qualifies for and have prevented me from under and over billing thousands of times over the last decade.


Here is a note for a high level hospital inpatient initial encounter (99223), high level hospital observation initial encounter (99220) and high level same day admission and discharge bundled care code 99236. 
C/C: My leg is red
HPI:  28 yo Male with 3 day history left calf pain. 6/10, dull, constant. Associated edema, erythema. (4 elements from HPI)
PFSH:  On no meds.  Smoker, Mother with eczema,  (All 3 elements documented)
ROS:  Except as dictated above, all other systems were reviewed and otherwise negative without further pertinent positives or negatives (10+ROS documented.  This notation is allowable under E/M rules)
Exam: 120/80 85 102.7 temp, well appearing (9 organ systems with at least 2 bullets each)
HENT:  Normal
Eyes:  Normal
CV:  Normal
Respiratory:  Normal
GI:  Normal
Psychiatric:  Normal
Lymphatic:  Normal
Neurological:  Normal
Skin:  Edema, warmth, redness right leg, lines consistent with cellulitis, marked with skin marker.
WBC 13K (1 point for documenting lab in complexity of data decision making section).  Venous Doppler report reviewed.  No clot.  (1 point for documenting review of a vascular study report in  complexity of data decision making). 
  1. Cellulitis (4 points for new problem, further workup planned under the number of diagnosis for medical decision making
Start antibiotics.  Reviewed case details with ER physician  Vitals stable.  General care appropriate. 1st dose of antibiotics given in ED (2 points for documenting discussion of case with another health care provider).  Continue work up with followup lab in am.  Follow glucose to verify lack of diabetes as this can change antibiotic coverage decisions.  Follow Cr to adjust antibiotic dosing.    See orders for full details.
This patient meets criteria for a level three initial hospital encounter because it contains all the required medically necessary and reasonable elements for a comprehensive history, a comprehensive physical exam and high complexity medical decision making.  All required components were achieved under history and physical exam criteria.  The only difference between the level three initial admission codes and the level 2 codes are the high vs moderate complexity in MDM.  History and physical element requirements are the same.

Medical decision making in this initial encounter is high complexity because this patient achieved 4 points for a new problem with further workup planned under the diagnosis component and they received 4 points under the data portion as well (1 + 1 + 2).   In this clinical example, the risk table does not apply.  However, I use the risk table every day to qualify my patients for level three initial care codes.  I think physicians constantly underestimate their level of risk because they deal with the same medical problems day in and day out and their daily encounters do not appear risky to them.  But remember,  the risk is for the patient, not for the physician.  Documentation of high risk drug toxicity  is frequently underestimated when choosing the level of E/M service. I highly recommend physicians read and understand the risk table to better understand why they are likely  undercoding every day.

The point system detailed above  is part of the Marshfield Clinic audit tool I use every day with my bedside E/M pocket cards detailed below.  High impact risk table elements are part of these cards.  I use them  to make sure my billing and coding accurately reflects the level of service I provide. Why am I able to document the things I did above and have it comply with E/M rules?  Detailed next are important points to remember when documenting the history, physical exam and MDM.  This information is referenced in detail directly from the E/M services guide linked above.



The information detailed below comes straight from the E/M services guide. Read and understand these important nuggets of information. What and how you document is far more important than the volume you document. Providing auditors with documentation you have provided the services listed below will elevate your level of service quite rapidly into higher levels of E/M service. You are already providing this service. Remember to document, document, document.
  • History
    • The chief complaint, ROS and PFSH may be listed as separate elements or included in the description of the HPI.
    • A ROS and PFSH obtained during an earlier encounter does not need to be re-recorded if there is evidence the physician reviewed and updated the previous information.    This update may be documented by describing new ROS  or PFSH information or noting there has been no change in the information and noting the date and location of the earlier ROS and or PMFSH.  The E/M services guide does not place a time limit on how far back the previous documentation can be reviewed.  
    • The ROS and PFSH can be recorded by ancillary staff or on a form completed by the patient and the physician must note they have reviewed and confirmed the information and supplement any other relevant information.
    • If the physician is unable to obtain a history from the patient or other source, the physician should describe the patient's condition which prevents obtaining a history.    
  • Physical Exam
    •  Specific abnormal and relevant negative findings of the affected or symptomatic body area(s) or organ systems(s) should be documented. Writing "abnormal" is not sufficient.
    • Abnormal findings on exam should be described
    • Writing "negative" or "normal" is sufficient to document normal findings related to unaffected areas or asymptomatic organ systems. 
  • Medical Decision Making (accurate  documentation of these issue can quickly increase level of MDM service being provided):
    • Number of Diagnoses and/or Management Options:
      •  Each diagnosis should have documentation that the problem is improved, controlled, resolving, resolved, uncontrolled, worsening or failing to change as expected.
      • For problems without a diagnosis, the assessment may be stated in the form of a differential diagnosis such as possible, probable, or rule out diagnosis.  
      • Document the initiation or change in treatment.  
    • Amount and/or Complexity of Data to be Reviewed:
      • Document a decision to obtain and review old medical records or obtain history from sources other than the patient, such as family or other caretakers. 
      • Document relevant findings from the review of old record or discussion with family or other caretakers.  Simply documenting "Old records reviewed" or "additional history obtained from family" without elaboration is not enough.
      • Document your discussion of contradictory or unexpected test results with the interpreting physician.
      • Document you personally reviewed an image or tracing or specimen.
      • Notations such as "wbc elevated" or "chest x-ray unremarkable" is acceptable.
    • Risk or Significant Complications, Morbidity, and/or Mortality
      • Remember to document comorbidities and other factors that increase the complexity of MDM by increasing the risk of complications, morbidity and mortality. 
      • Referral for urgent invasive procedures and surgeries should be documented or implied.
      • USE THE TABLE OF RISK!  That's what it's there for.  I have detailed the most common risk elements I use in my daily practice on my E/M card shown below.   
    • There are many other points to consider when documenting MDM.  There are too many to list here individually, but most are described in the MDM portion of my E/M bedside pocket cards detailed below.  In addition, I recommend reviewing pages 13-15 of the E/M services guide for a thorough understanding of the finer points of E/M coding.


What is the distribution of CPT® 99221, 99222 and 99223 for internal medicine in the country? One Medicare contract carrier actually told us the answer (link no longer available) in a January, 2013 pdf presentation (based on January 2011 through December 2011 data). I was unable to find data on the other initial hospital care codes 99220 and 99236. Here is their analysis.
  • 99221:  about 4% of total for these hospital initial visit codes. 
  • 99222: about 28% of total for these hospital initial visit codes.
  • 99223: about 68% of total for these hospital initial visit codes.
One additional resource described the ten year trend (2001-2010) of E/M coding trends.   The OIG published a report in May, 2012 titled Coding Trends of Medicare Evaluation and Management Services.    As you can see, the proportion of 99221 vs 99222 vs 99223 has remained consistently constant over the last 10 years.  This data is for all Medicare E/M charges in this code group and not limited to internal medicine.  In 2010, 55% of initial inpatient hospital care codes were 99223, 36% were 99222 and 9% were 99221.

In the same resource (on page 23), the OIG also published ten year E/M coding trends for the initial observation admission codes 99218-99220 and the admit and discharge same day codes 99234-99236.    This data is not exclusive to internal medicine.  A trend toward submitting higher intensity of service was observed.  The national distribution for  initial observation care codes in 2010 was 54% for 99220, 36% for 99219 and 11% for 99218.  For the admission and discharge same day codes, the 2010 data data showed the proportions as 40% for 99236, 41% for 99235 and 19% for 99234.

How often are CPT® codes 99223, 99220 and 99236 billed to Medicare?  Here is data from the most recent 2011 CMS Part B National Procedure Summary Files data (2011 zip file) showing how many CPT® 99223, 99220 and 99236 encounters were billed and the dollar value of their services for Part B Medicare.
  • 99223
    • Allowed services - 11,771,925
    • Allowed charges - $2,309,383,654.87
    • Payments - $1,813,667,113.89
  • 99220
    • Allowed services - 684,277
    • Allowed charges - $102,373,631.06
    • Payments - $79,026,818.51
  • 99236
    • Allowed services - 160,118
    • Allowed charges - $34,409,071.27
    • Payments - $26,719,247.86


How much money does a CPT ® 99223, 99220 and 99236 pay in 2017?  That depends on what part of the country you live in and what insurance company you are billing.    All CPT® codes are paid in relative value units (RVUs).  I have previously discussed the complex nature of RVUs.  You can find that discussion here.  Here are the raw RVU values and their dollar value in my geographical area:
  • 99223:  Work RVU 3.86.  Total RVU 5.73.  Dollar value of about $194
  • 99220:  Work RVU 3.56.  Total RVU 5.25.  Dollar value about $178
  • 99236:  Work RVU 4.20.  Total RVU 6.16.  Dollar value about $209.
A complete list of RVU values on common hospitalist E/M codes can be found here.  The 2017 RVU dollar value conversion rate is 35.8887.  You can see many more of my  E/M lectures here.

I've tried to make this complex process as simple as possible to help others understand how important documentation is to stay compliant and to get appropriately paid for the work they are providing.  It took me years of daily diligence and carrying my E/M pocket reference card around  with me at all times to get comfortable with medical billing and coding.  Remember, what code you bill is entirely dependent on how you document, not how much you document.


EM Pocket Reference Cards Using Marshfield Clinic Point Audit

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