Billing CPT 99234, 99235, 99236 with example

here are 3 codes for Observation admission and discharge of a patient in the same day. these are 99234, 99235 and 99236.

The inpatient and outpatient E and M codes all have the same format. New Patient? You must meet all 3 criteria. In this case it all admitted patients are considered new patients in house....

So these criteria are very similar to outpatient encounters.

The 99236 requires:

1. Comprehensive history
2. Comprehensive Examination
3. Medical decision Making of High Complexity

The Comprehensive history is:
1. A chief complaint
2. An extended HPI (four HPI elements OR the status of three chronic or inactive probs.
3. A 10 system ROS
4. A Complete PFSH. Which includes Meds, Allergies, FamHx, SrgHx, MedHx
Remember it only takes on element from each category of the PFSH to qualify as complete.

The Comprehensive Examination is 2 points from 9 organ systems


1) Three vital signs
2) General appearance

1) Inspection of conjunctivae and lids
2) Examination of pupils and irises (PERRLA)
3) Ophthalmoscopic discs and posterior segments
Ears, Nose, Mouth, and Throat

1) External appearance of the ears and nose (overall appearance, scars, lesions, masses)
2) Otoscopic examination of the external auditory canals and tympanic membranes
3) Assessment of hearing
4) Inspection of nasal mucosa, septum and turbinates
5) Inspection of lips, teeth and gums
6) Examination of oropharynx: oral mucosa, salivary glands, hard and soft palates, tongue, tonsils and posterior pharynx


1) Examination of neck (e.g., masses, overall appearance, symmetry, tracheal position, crepitus)
2) Examination of thyroid

1) Assessment of respiratory effort (e.g., intercostal retractions, use of accessory muscles, diaphragmatic movement)
2) Percussion of chest (e.g., dullness, flatness, hyperresonance)
3) Palpation of chest (e.g., tactile fremitus)
4) Auscultation of the lungs

1) Palpation of the heart (location, size, thrills)
2) Auscultation of the heart with notation of abnormal sounds and murmurs
3) Assessment of lower extremities for edema and/or varicosities
4) Examination of the carotid arteries (e.g., pulse amplitude, bruits)
5) Examination of abdominal aorta (e.g., size, bruits)
6) Examination of the femoral arteries (e.g., pulse amplitude, bruits)
7) Examination of the pedal pulses (e.g., pulse amplitude)
Chest (Breasts)

1) Inspection of the breasts (e.g., symmetry, nipple discharge)
2) Palpation of the breasts and axillae (e.g., masses, lumps, tenderness)
Gastrointestinal (Abdomen)

1) Examination of the abdomen with notation of presence of masses or tenderness
2) Examination of the liver and spleen
3) Examination for the presence or absence of hernias
4) Examination (when indicated) of anus, perineum, and rectum, including sphincter tone, presence of hemorrhoids,
rectal masses
5) Obtain stool for occult blood testing when indicated
Genitourinary (Male)

1) Examination of the scrotal contents (e.g., hydrocoele, spermatocoele, tenderness of cord, testicular mass)
2) Examination of the penis
1) Digital rectal examination of the prostate gland (e.g., size, symmetry, nodularity, tenderness)
Genitourinary (Female)

Pelvic examination (with or without specimen collection for smears and cultures, which may include:

1) Examination of the external genitalia (e.g., general appearance, hair distribution, lesions)
2) Examination of the urethra (e.g., masses, tenderness, scarring)
3) Examination of the bladder (e.g., fullness, masses, tenderness)
4) Examination of the cervix (e.g., general appearance, discharge, lesions)
5) Examination of the uterus (e.g., size, contour, position, mobility, tenderness, consistency, descent or support)
6) Examination of the adnexa/parametria (e.g., masses, tenderness, organomegaly, nodularity)

Palpation of lymph nodes
two or more areas:

1) Neck
2) Axillae
3) Groin
4) Other

1) Examination of gait and station
2) Inspection and/or palpation of digits and nails (e.g., clubbing, cyanosis, inflammatory conditions, petechiae, ischemia, infections, nodes)

Examination of the joints, bones, and muscles of one or more of the following six areas:

a) head and neck
b) spine, ribs, and pelvis
c) right upper extremity
d) left upper extremity
e) right lower extremity
f) left lower extremity

The examination of a given area may include:

1) Inspection and/or palpation with notation of presence of any misalignment, asymmetry, crepitation,
2) defects, tenderness, masses or effusions
3) Assessment of range of motion with notation of any pain, crepitation or contracture
4) Assessment of stability with notation of any dislocation, subluxation, or laxity
5) Assessment of muscle strength and tone (e.g., flaccid, cogwheel, spastic) with notation of any atrophy or abnormal movements

1) Inspection of skin and subcutaneous tissue (e.g., rashes, lesions, ulcers)
2) Palpation of the skin and subcutaneous tissue (e.g., induration, subcutaneous nodules, tightening)

1) Test cranial nerves with notation of any deficits
2) Examination of DTRs with notation of any pathologic reflexes (e.g., Babinksi)
3) Examination of sensation (e.g., by touch, pin, vibration, proprioception)

1) Description of patient’s judgment and insight

Brief assessment of mental status which may include

1) orientation to time, place, and person
2) recent and remote memory
3) mood and affect

Lastly for all admitted patients you must ALSO meet the third criteria.....Medical Decision Making.....

MDM for short. In this case 99236 the medical decision making must be of high complexity. Which is ALWAYS a bear, unless you know how to do it.

MDM is judged by 3 criteria.

  • Problem Points, 4 points required
  • Data Points, 4 Points Requires
  • Risk Chart, High Risk
Luckily, you only need 2 of 3 criteria to qualify for the Highest Level of MDM. Most people accomplish this feat through data and problem points....

Always hit the problem and the data points, Strive to hit risk….

You need Four Problem Points

New Problem with work up (4)
New problem no Work up (3)
Est Problem, Worsening (2)
Est Problem Stable(1)

Four Data Points
Labs(1) Ordered OR Reviewed
Indep Review of EKG/Film/Specimen (2)
Reviewed Old records (2)
Decision to Obtain Old Records (1)
Discuss test with Physician(1)
Order Test EKG/Cath/PFTs (1)

Risk, to be high risk
1 New Problem which poses a threat to life or limb
1 chronic illness with severe exacerbation
1 change in neurologic status

Or if you chose to do

1. Cardiovascular imaging, with contrast
2. Cardiac EP studies
3. Diagnostic endoscopies
4. Discography
5. Elective major surgery
6. Emergency major surgery
7. Parenteral controlled substances
8. Drug therapy requiring intensive monitoring for toxicity (Digoxin/Heparin)
9. Decision not to resuscitate, or to de-escalate care because of poor prognosis
Or the decision to do the following

Most of these things aren't done on an ambulatory basis, so you are essentially screwed with the risk part of this.

In other words, YOU CAN ONLY BILL 99236 IFF you meet the Problem AND Data points. IF you do not, you cannot likely make the grade for a 99236.

Hospital Observation Services During Global Surgical Period

The global surgical fee includes payment for hospital observation (codes 99217, 99218, 99219,99220, 99224, 99225, 99226, 99234, 99235, and 99236) services unless the criteria for use of CPT modifiers “-24,” “-25,” or “-57” are met. Contractors must pay for these services in addition to the global surgical fee only if both of the following requirements are met:

• The hospital observation service meets the criteria needed to justify billing it with CPT modifiers “-24,” “-25,” or “-57” (decision for major surgery); and

• The hospital observation service furnished by the surgeon meets all of the criteria for the hospital observation code billed.

Examples of the decision for surgery during a hospital observation period are:

• An emergency department physician orders hospital outpatient observation services for a patient with a head injury. A neurosurgeon is called in to evaluate the need for surgery while the patient is receiving observation services and decides that the patient requires surgery. The surgeon would bill a new or established office or other outpatient visit code as appropriate with the “-57” modifier to indicate that the decision for surgery was made during the evaluation. The surgeon must bill the office or other outpatient visit code because the patient receiving hospital outpatient observation services is not an inpatient of the hospital. Only the physician who ordered hospital outpatient observation services may bill for observation care.

• A neurosurgeon orders hospital outpatient observation services for a patient with a head injury. During the observation period, the surgeon makes the decision for surgery. The surgeon would bill the appropriate level of hospital observation code with the “-57” modifier to indicate that the decision for surgery was made while the surgeon was providing hospital observation care.

Examples of hospital observation services during the postoperative period of a surgery are: A surgeon orders hospital outpatient observation services for a patient with abdominal pain from a kidney stone on the 80th day following a TURP (performed by that surgeon). The surgeon decides that the patient does not require surgery. The surgeon would bill the observation code with CPT modifier “-24” and documentation to support that the observation services are unrelated to the surgery.

• A surgeon orders hospital outpatient observation services for a patient with abdominal pain on the 80th day following a TURP (performed by that surgeon). While the patient is receiving hospital outpatient observation services, the surgeon decides that the patient requires kidney surgery. The surgeon would bill the observation code with HCPCS modifier “-57” to indicate that the decision for surgery was made while the patient was receiving hospital outpatient observation services. The subsequent surgical procedure would be reported with modifier “-79.”

• A surgeon orders hospital outpatient observation services for a patient with abdominal pain on the 20th day following a resection of the colon (performed by that surgeon). The surgeon determines that the patient requires no further colon surgery and discharges the patient. The surgeon may not bill for the observation services furnished during the global period because they were related to the previous surgery.

An example of a billable hospital observation service on the same day as a procedure is when a physician repairs a laceration of the scalp in the emergency department for a patient with a head injury and then subsequently orders hospital outpatient observation services for that patient. The physician would bill the observation code with a CPT modifier 25 and the procedure code.

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