What Is CPT Code 99222 for Initial Hospital Care?

Current Procedural Terminology (CPT) codes serve as a standardized language for healthcare providers, describing medical, surgical, and diagnostic services for billing and record-keeping purposes. These codes are maintained by the American Medical Association (AMA) and are fundamental to how healthcare services are documented and reimbursed across the United States. Among these, CPT code 99222 is specifically used for initial hospital care, representing a particular level of evaluation and management services provided to patients.

What CPT Code 99222 Represents

CPT code 99222 designates “initial hospital inpatient or observation care, per day, for the evaluation and management of a patient.” This code signifies the beginning of a patient’s care in either an inpatient hospital setting or an observation status, applying to the first day of service. It falls within the 99221-99223 series for initial hospital visits, representing a moderate level of evaluation and management services.

The use of CPT code 99222 requires documentation of a medically appropriate history and/or examination, along with a moderate level of medical decision making (MDM). The complexity of medical decision making or the total time spent on the encounter are the primary factors used to determine the appropriate code level. For code selection based on time, a minimum of 55 minutes must be met or exceeded on the date of the encounter. This time includes both face-to-face and non-face-to-face activities performed by the healthcare professional related to the patient’s care on that day.

Effective January 1, 2023, observation services are now billed using the same CPT codes as hospital inpatient care, including 99221-99223. This change consolidates coding for initial care whether a patient is formally admitted as an inpatient or placed under observation status. The code applies to the admitting physician’s initial service, encompassing all related care provided on that first day, even if some services occurred prior to formal admission in other settings like an emergency department.

Elements Determining the Level of Service

To accurately select an evaluation and management (E/M) code like CPT 99222, healthcare providers assess key components of the patient encounter. While history and examination are performed, the level of service is primarily determined by medical decision making or total time spent.

Patient history involves gathering information about the individual’s health status and past medical events. This includes the chief complaint, history of present illness, review of systems, and past, family, and social history. The extent of this information gathering can vary from problem-focused to comprehensive, depending on the patient’s needs.

A physical examination involves a hands-on assessment of the patient’s body. The examination can range in scope, from a problem-focused assessment of a single affected area to a comprehensive review of multiple organ systems. Healthcare providers determine the appropriate level of examination based on the patient’s presenting problem and clinical judgment.

Medical decision making (MDM) is a central element in determining the complexity of care, reflecting the cognitive effort involved in managing a patient’s condition. MDM is assessed by three factors: the number and complexity of problems addressed, the amount and complexity of data reviewed and analyzed, and the risk of complications and/or morbidity or mortality of patient management.

The number and complexity of problems considers how many issues are addressed and their difficulty, ranging from straightforward, self-limited problems to severe, life-threatening illnesses. Data reviewed can include laboratory results, imaging studies, external records, and independent interpretations of tests. The risk element evaluates potential dangers associated with the patient’s condition and treatment options, such as decisions regarding prescription drug management or major surgery. To qualify for a specific MDM level, two of these three elements must be met or exceeded.

Time can also be used as the primary factor for selecting the E/M code level, particularly for hospital inpatient or observation care services. This total time includes all physician or qualified healthcare professional time spent on the date of the encounter, encompassing both face-to-face patient contact and non-face-to-face activities like reviewing records, ordering tests, or coordinating care. The specific time thresholds vary by code level, providing an alternative method for determining the appropriate service complexity.

Differentiating Levels of Initial Hospital Care

The CPT code series 99221, 99222, and 99223 are used for initial hospital inpatient or observation care, with each code representing a distinct level of service complexity. The variations in the required medical decision making (MDM) or total time spent differentiate these codes, allowing for precise billing based on the intensity of care provided.

CPT code 99221 is designated for initial hospital care involving straightforward or low-level medical decision making. This level applies to patients with less complex conditions requiring minimal data review and lower risk management. If time is the basis for code selection, 99221 requires a total time of 40 minutes or more on the day of the encounter. An example might be a patient admitted for a straightforward, stable condition that poses little immediate threat or diagnostic challenge.

CPT code 99222 represents initial hospital care with a moderate level of medical decision making. This complexity level involves a greater number or complexity of problems, more data to review, or a moderate risk of complications. When time is used, 99222 requires a total of 55 minutes or more spent on the patient’s care on the date of admission. This code is commonly used for patients who are sick but stable, often requiring prescription drug management or decisions regarding minor surgery with risk factors.

CPT code 99223 is reserved for initial hospital care involving a high level of medical decision making. This highest complexity level is characterized by severe exacerbations of chronic conditions, life-threatening illnesses, extensive data review, or high risk of morbidity or mortality. For time-based selection, 99223 requires 75 minutes or more of total time spent on the patient’s care on the admission date. Scenarios like decisions regarding emergency major surgery, intensive drug therapy requiring close monitoring, or managing multiple unstable chronic conditions would fall under this code.

The selection among these codes relies on thorough documentation that supports the chosen level of medical decision making or the total time spent. This ensures that the services billed accurately reflect the work, knowledge, and time invested by the healthcare provider in initiating inpatient or observation care.