99233 CPT code 7 high risk
A 99233 CPT code explanation, 99223 examples, 99233 example note, 99233 RVU amount, 99233 wRVU / work RVU amount and a 99233 template for EMR.
What is CPT Code 99233?
CPT code 99233 is assigned to a level 3 hospital subsequent care (follow up) note. 99233 is the highest level of non-critical care daily progress note. When it comes to 99233 documentation is critical, however understanding of the documentation required is even more critical. WorK RVU (wRVU) for cpt code 99233 is of course higher than that for 99232.
How many work RVU (wRVU) are given for a 99233?
A 99233 CPT code is associated with 2.0 work RVU’s also known as wRVU.
A 99223 = 2 wRVU
In general when is a 99223 code appropriate?
When it comes to coding, documentation is key and you would be surprised to see just how little writing is required to ensure all the key criteria. My personal rule however is that common sense should prevail as opposed to trying to game a system with documentation.
If a patient is improving or remains stable CPT code 99233 is probably not appropriate. Many times, rounds are made on patients where it is essentially a continue meds, continue monitoring, improving basis, essentially a courtesy visit. These are not meant to be 99233’s.
Often, for example the day after a patient is admitted, many management decisions continue to evolve and treatment changes are made. For example blood pressure control or heart failure would require specific medication adjustment and tests that need to be reviewed. Development of renal failure for example that would require holding meds, getting tests, following them and potentially arranging consultation and discussing with specialists. This would be a classic 99233 CPT code type situation. In general, as the patient improves to a state where they are improved and awaiting final stabilization for discharge, CPT code 99232 rather than 99233 would be appropriate.
Example of hospital days where CPT code 99233 may be appropriate as long as the documentation is correct
Admission – Patient with shortness of breath and chest pain, comorbidities present, diagnosed with congestive heart failure and known ischemic cardiomyopathy treated medically, IV meds given, complexity is high.
CPT code 99223
Day 2 – Patient improved, meds changed to PO, home meds restarted, no invasive tests planned, continuing to monitor.
CPT code 99232
Day 3 – Kidney function worsens, meds held and changed appropriately, concern for cardiac output being low, nephrology consulted, situation worsened from prior day.
CPT code 99233
Day 4 – Echo reviewed, cardiac function worse than thought, thinking about right heart cath, dobutamine started on floor, IV diuresis ongoing, discussed with consultants.
CPT code 99233
Day 4 – Situation improves, renal function stabilizes with inotropic support and renal recommendations, breathing improved, meds regimen stable, labs and CXR stable, patient likely to be discharged in next few days.
CPT code 99232
Documentation is critical when it comes to a 99233
Since 99233 is higher levels of billing when it comes to inpatient follow up, it is likely to come under more scrutiny and therefore documentation and understanding of requirements is critical. In general, many inpatients are truly sick and if there is genuinely high complexity in terms of the patient and the situation the documentation will take care of it by itself. When we take a deeper dive in to the guidelines for documentation it becomes ridiculously convoluted and takes an investment of time to truly develop an understanding to where it can be applied. Once that understanding is developed the whole thing becomes much easier. Unfortunately a note becomes like a point system where a certain number of points are required for a certain number of categories. That can be advantageous however when it comes to efficiency in documentation for those that understand how it works.
The key Components of a 99233
To bill a 99233 you need at least 2 of the 3 key components.
Detailed interval history
Detailed examination
High complexity decision making
See below for a more detailed breakdown of these categories
Typically one would also:
Coordinating care with other providers
Counseling patient and family
Alternatively a 99233 can be billed on the basis of time as described below.
Time based 99233
The 99233 represent what would typically be 35 minutes of care at the patient bedside or on the patient’s floor or unit.
If 35 minutes was spent with a patient, if there is specific documentation, it is felt that the time alone may justify the 99233. That documentation must include 1) Total time spent (>35mins) 2) Description of the counseling and care coordination 3) State that over half the time was spent on counseling and coordinating specifics of care.
Detailed interval history
4 HPI elements (locations/severity/duration/associated symptoms etc.) or the status of 3 chronic problems
99233 Examples of interval history:
Chest pain (1) exacerbated last night, left chest (2), radiates to neck (3), sharp (4) and intermittent in nature (5), associated shortness of breath (6).
Shortness of breath (1) noted last night, intermittent (2) and occurring at rest, no relation to exertion (3), no chest pain (4), no nausea (5) or diaphoresis (6).
These examples contain more than the 4 elements required for the HPI element of the 99233. If a patient has a worsening of a condition and it is described appropriately then this should be easily fulfilled.
Note that if there isn’t a 4 point interval HPI, documentation of the status of 3 chronic medical conditions and 2 review of systems are reportedly acceptable surrogates for this in a 99233.
Detailed examination
12 bullet points from any organ system
Also described as 6 areas with 2 bullets each, or 2+ areas with 12 total bullets
1 point includes 3 vital signs reviewed
1 point for general appearance
1 point each for Neck / lung / heart / carotids / abdomen / liver / edema / digits / skin / mental status / neuro etc.
In general I would say include 6 organ systems regardless.
99233 examples of detailed exam:
In this cardiac strong exam we have 9 different ‘systems’ which fulfills the 6 suggested, we have 15 bullets, this exceeds the required 12.
1 point for these 3 vital signs
BP 127/84, HR 75, 02sat 96% on air (1 point for the 3 vitals)
1 point for this general exam
Laying in bed, mild increase work of breathing
1 point for this mental status exam
Alert and oriented, can follow instruction
5 points for this cardiovascular exam
Regular rhythm, soft systolic murmur, no added sounds (auscultation of heart)
Forceful apical beat (palpation of the heart)
Normal carotid upstrokes (palpation of carotid)
2+ femoral and radial pulses (examination of peripheral arteries)
1+ bilateral pitting edema (exam of periphery cardiovascular)
1 point for this musculoskeletal exam
No cyanosis or clubbing noted in the digits
1 point for this exam of neck
JVP 10cm, elevated, bed at 45 degrees
2 points for this respiratory exam
Lungs clear to auscultation bilaterally
Respiratory effort mildly increased
2 points for this abdominal exam
Soft and non tender, No masses felt
Auscultation normal bowel sounds
1 point for skin
No new rashes or ulceration noted
High complexity decision making – For a 99233, documentation needs to include at least 2 out of 3 of the following
Extensive management options for diagnosis / treatment
Extensive data to be reviewed
Labs / Radiology tests / PT/OT notes / Consultants notes / Tests to be ordered documented
High risk of complications or comorbidity
Comorbidity documentation that pertains to presenting issues
Risks associated with tests ordered or performed
Risks associated with management issues
For a 99233 typically a combination (2 out of 3 needed) of 4 problem points, 4 data points, and documentation of high risk.
99233 high complexity decision making – 4 problem points
Minor problem points (maximum of 2) = 1 point
Established problem that is stable or demonstrates improvement =1 point
Established problem that worsens = 2 points
New problem with no further work up planned (max of 1) = 3 points
New problem, with additional work-up needed =4 points
99233 high complexity decision making – 4 Data Points
Review or order labs =1 point
Review or order imaging =1 point
Discuss test with performing physician =1 point
Independently review image / tracing / specimen =2 points
Decide to obtain old records =1 point
Review and summarize old records =2 points
99233 high complexity decision making -Demonstration of High Risk
Needs one of the following 3 elements
Presenting problems
Diagnostic procedures
Management options
Presenting problems
One or more chronic illness with exacerbation or progression
Acute or chronic illness posing a threat to life or organ system (resp distress / pulmonary embolism / myocardial infarction / acute kidney injury etc..)
Diagnostic procedures
Contrasted cardiac studies
Endoscopy
EP studies
Management options
Elective or emergency major surgery
IV controlled therapy
Drug therapy requiring monitoring for toxicity
DNR or establishment of supportive care only
Comprehensive templates for 99233
Here is a comprehensive template for a 99233. I’m sure people will argue that its overkill and takes a lot of time, however I disagree. If these elements are reviewed it clearly improves patient care as multiple pertinent and often ignored elements will be reviewed and taken in to account and can influence decision making. The documentation is comprehensive and in reality not overly time consuming in the era of EMR, particularly if auto-population is used and you are familiar with the patient. If a significant portion of these elements is followed you will much more than fulfill the documentation criteria for a 99233. For those learning the specifics of documentation I would suggest starting comprehensive like this then when you feel comfortable the note can be trimmed significantly and tailored to needs.
Interval HPI;
(If new issue has arisen then state here and if possible describe with 4 points and associated symptoms)
Lab review;
(Pull in lab values if desired)
(Comment on any changes on the review)
Test Review;
(Pull in radiology testing) New radiology tests include
(CXR reading and review) CXR was reviewed and demonstrated
(EKG 12 lead reading and review) 12 lead EKG was reviewed and demonstrated
(Telemetry review and comment) Telemetry was reviewed and demonstrated
Meds;
(Pull in meds if required)
Physical Exam;
(Pull in BP, HR, temp, 02sat)
(Laying in bed / sitting in chair / ambulating)
(Comfortable / uncomfortable / other comment)
(Alert and oriented, able to answer questions)
(JVP is not elevated, carotid exam normal)
(Regular rate and rhythm, no murmurs noted, no added heart sounds, normal apical pulsation)
(2+ radial pulses bilateral, 2+ femoral/tibial pulses bilaterally)
(no edema in the lower extremities)
(no clubbing or cyanosis)
(Lungs clear to auscultation bilaterally, respiratory effort normal)
(Abdomen soft and non tender, normal bowel sounds)
(No new rashes or ulceration noted)
Problems
(Problem list being actively managed)
(Significant new problems interval – work up ordered, treatment started)
(Problem 1 – stable / treating, – management)
(Problem 2 – stable / treating, – management)
(Problem 3 – stable / treating, – management)
(Problem 4 – stable / treating, – management)
Specifics to the 99233
(Discussion with other consultants)
(Discussion with patient and family)
(Review of other notes)
(Obtain old records / summarize old records)
(New studies ordered)
(Code status review)
(IV controlled therapy)
(Drugs being monitored for toxicity)
Comprehensive cardiology centered template example for 99233 – see below for a detailed breakdown and discussion
Interval HPI;
Shortness of breath worsened overnight, caused to wake from sleep, worse with exertion and lying flat, no further chest pain, no nausea or diaphoresis.
Lab review;
Labs reviewed
BNP is elevated
Cr increased from 1.1 to 1.6
Troponin trend 0.11 to 0.13
ABG showed some hypoxemia
Test Review;
CXR was reviewed and demonstrated findings consistent with worsening of pulmonary edema
12 lead EKG was reviewed and demonstrated sinus rhythm at a rate of 90
Telemetry was reviewed and demonstrated sinus rhythm rate 80-110
Meds;
Medication list or can simply say was reviewed
Physical Exam;
BP 100/70, HR 90, temp 98.0, 92% 02sat on 4 liters
Alert and oriented and able to answer questions
Laying in bed
Mildly increased work of breathing
JVP elevated to 10cm at 45degrees, carotid upstroke normal
Cardiac exam, irregular rhythm, no murmurs noted, no added heart sounds, normal apical pulsation
2+ radial pulses bilateral, 2+ femoral bilaterally
1+ bilateral pitting edema in the lower extremities
No clubbing or cyanosis
Lungs have mild creps at bases bilaterally, respiratory effort normal
Abdomen soft and non tender, normal bowel sounds
No new rashes or ulceration noted
Problems
NSTEMI, s/p PCI
Atrial fibrillation, chronic
Hypertension, chronic, controlled
Diabetes Mellitus, controlled
CHF, acute on chronic systolic
AKI on likely CKD
Interval new issues
CHF / AKI – Interval development of respiratory distress and acute kidney injury. Likely congestive heart failure exacerbation, will order echocardiogram to assess LV function, intravenous Lasix administered, will hold ACE inhibitor in the setting of AKI, continue other meds as stated, monitor renal function closely
Ongoing Issues
NSTEMI / CAD – s/p PCI to RCA 4 days ago, continue aspirin and Plavix, continue BB, holding ACE due to AKI, checking echocardiogram to assess LV function
Hypertension – currently normotensive, holding ACE, continue other meds listed
Atrial fibrillation – rate controlled, continue beta blocker, continue Coumadin for anticoagulation, INR is 1.8 aiming for 2.0-2.5. Will discuss with pharmacy.
Specifics to the 99233
Discussed with general medicine team
Discussed with patient who understands issues and daughter at bedside
General medicine note reviewed
Old echo reviewed, EF was 55%, repeat pending
New echocardiogram ordered
Remains Full Code
No IV controlled therapy started
Monitoring Coumadin with INR, co-managing with pharmacy
Detailed Breakdown of the 99233 note template and example.
The example above is a relatively extensive documentation, it would take some people a long time to do that and others could run through it relatively quickly. In my opinion, if there is truly a higher level of care such as a 99233, the time and documentation should reflect that. It can, if methodically done, be in an efficient manner.
By no means is all the documentation above needed. The note basically scores top points in every requirement, and remember only 2 out of the 3 are needed.
Interval HPI
Shortness of breath worsened overnight, caused to wake from sleep, worse with exertion and lying flat, no further chest pain, no nausea or diaphoresis.
This has already hit over the 4 points required. Theoretically only 1 of the other 2 categories (physical exam and complex decision making) is now needed.
Note that if there isn’t a 4 point interval HPI, documentation of the status of 3 chronic medical conditions and 2 review of systems are acceptable surrogates.
Lab review;
Labs reviewed
BNP is elevated
Cr increased from 1.1 to 1.6
Troponin trend 0.11 to 0.13
ABG showed some hypoxemia
The review of the labs contribute a point to the data point section of the medical decision making section. Remember, 4 data points are needed. Also the increase in creatinine supports the AKI as a new critical diagnosis, the BNP supports CHF acute exacerbation and the hypoxemia supports respiratory distress. Remember, a new significant problem with additional work up planned fulfills 4 points and already qualifies for high risk.
Test Review;
CXR was reviewed and demonstrated findings consistent with worsening of pulmonary edema
12 lead EKG was reviewed and demonstrated sinus rhythm at a rate of 90
Telemetry was reviewed and demonstrated sinus rhythm rate 80-110
Personally reviewing the radiology test CXR is 2 point. Independent review of the EKG is 2 points (If we had decided to review old records and summarized that would have been 2 points). Later we order an echo, that’s a further point. We had already reviewed the lab above, that’s a further point. In total here we have 6 data points that exceeds the 4 data points required for the 99233. That’s already one of the 2 requirements of the complex medical decision making out the way. Remember it has to be 2 out of the 3 of 4 problem points, 4 data points and high risk. We already have evidence for the new significant diagnosis / problem point above so in theory this note already qualifies for a 99233.
Physical Exam;
BP 100/70, HR 90, temp 98.0, 92% 02sat on 4 liters (1 point)
Alert and oriented and able to answer questions (1 point)
Laying in bed (1 point)
Mildly increased work of breathing in general (1 point)
JVP elevated to 10cm at 45degrees, carotid upstroke normal (1 point)
Cardiac exam, irregular rhythm, no murmurs noted, no added heart sounds, normal apical pulsation (2 points)
2+ radial pulses bilateral, 2+ femoral bilaterally (1 point)
1+ bilateral pitting edema in the lower extremities (1 point)
No clubbing or cyanosis (1 point)
Lungs have mild creps at bases bilaterally, respiratory effort normal (1 point)
Abdomen soft and non tender, normal bowel sounds (2 points)
No new rashes or ulceration noted (1 point)
Remember that a total of 12 bullets are needed. Ideally 6 organ systems at least. Can be 12 bullets from at least 2 technically. 3 vital signs are 1 point and general appearance is 1 point. In the exam above we have a total of 14 points, we have 6 organ systems, it easily fulfills requirements.
Problems
NSTEMI, s/p PCI (established problem, stable 1 point)
Atrial fibrillation, chronic (established problem, stable, 1 point)
Hypertension, chronic, controlled (established problem, stable, 1 point)
Diabetes Mellitus, controlled (established problem, stable, 1 point)
These 4 stable points are ok as they are issues that significantly impact treatment.
CHF, acute on chronic systolic (established problem, worsening (2 points) vs. new problem significantly threatening issue with further work up planned (4 points)
AKI on likely CKD (new problem, significantly threatening issues, further work up planned (4 points).
Once again, our documentation here is basically worth 12 problem points, remember we only need 4; the acute CHF or the AKI would alone have been enough to suffice.
Interval new issues
CHF / AKI – Interval development of respiratory distress and acute kidney injury. Likely congestive heart failure exacerbation, will order echocardiogram to assess LV function, intravenous Lasix administered, will hold ACE inhibitor in the setting of AKI, continue other meds as stated, monitor renal function closely
Ongoing Issues
NSTEMI / CAD – s/p PCI to RCA 4 days ago, continue aspirin and Plavix, continue BB, holding ACE due to AKI, checking echocardiogram to assess LV function
Hypertension – currently normotensive, holding ACE, continue other meds listed
Atrial fibrillation – rate controlled, continue beta blocker, continue Coumadin for anticoagulation, INR is 1.8 aiming for 2.0-2.5. Will discuss with pharmacy.
In the section above we have simply bolstered our documentation above. We have laid out the problems that are new and significantly threatening and demonstrated the further work up planned. We have reported the management of the chronic issues. We have documented tests planned and discussions had.
Specifics to the 99233
Discussed with general medicine team
Discussed with patient who understands issues and daughter at bedside
General medicine and PT note reviewed
Old echo reviewed, EF was 55%, repeat pending
New echocardiogram ordered
Remains Full Code
No IV controlled therapy started
Monitoring Coumadin with INR, co-managing with pharmacy
The discussion with the other physicians involved and also the discussion with the family is a supporting factor for complexity. The review of the medical and the PT notes can act as a point in data. The old echo review can act as a point in data.
The ordering of the new echo acts as a data point also. If this had been a CT angiogram, cath, or other contrasted cardiac scan, or endoscopy for example, it would have actually fulfilled the entire criteria for high risk. If there was IV parenteral therapy, i.e IV pain meds that are controlled, then that also would have acted as high risk. The INR monitoring for the Coumadin, given its significantly high risk for toxicity and need for monitoring can act as a high risk feature also.
Brief note example that fulfills the criteria for a 99233
I’m not a fan of minimalist notes, I think it can breed complacency and doesn’t help with the thought process. The following shows however that when sticking to the criteria for a 99233 we can still achieve what we need to with a minimal note.
Interval history
Shortness of breath worsened overnight, PND, worse with exertion and lying flat, no chest pain, nausea or diaphoresis.
4 interval HPI points satisfied with a worsening shown
Objective points
BP 100/70, HR 90, temp 98.0, 92% 02sat on 4 liters
Alert and oriented, anxious, mildly increased WOB, JVP 10cm, carotid normal, irregular rhythm, no heart murmurs noted, normal apical pulsation, 2+ femoral bilaterally, 1+ bilateral pitting edema in the lower extremities, No clubbing or cyanosis, lungs have mild creps at bases bilaterally, respiratory effort normal
Abdomen soft and non tender, normal bowel sounds No new rashes or ulceration noted
Theoretically we could stop here, we have 2 of the 3 main sections with all criteria fulfilled, interval HPI has 4 points and the physical exam has 12 bullets with 6 systems. This highlights how knowledge of what’s required can allow focus on main issues if that is the aim. In reality the note will continue thought.
Assessement
New respiratory distress, CHF acute exacerbation
Acute Kidney injury
INR is 1.8, patient on coumadin
Both of the above are 4 points each, just one of them would suffice for the medical decision making high complexity requirement. The INR and Coumadin and need for monitoring demonstrate a high risk. In theory this is all that’s needed, you could even take out the physical exam section and still have fulfilled 2/3 requirements as needed.
Plan
IV diuresis, repeat echocardiogram, stop ACE inhibitor, monitor renal function
This note was very short, but still way over the requirement in terms of points needed, essentially its point system dense and easily fulfills the documentation needs for a 99233.
Even briefer note example that fulfills the criteria for a 99233
Interval history
Shortness of breath worsened overnight, PND, worse with exertion and lying flat, no chest pain, nausea or diaphoresis.
4 interval HPI points satisfied with a worsening shown
Objective points
Technically the exam isn’t required
4 data points can be; EKG reviewed no significant ST-T changes (2 points). CXR discussed with radiology concern for pulmonary edema (1 point). Creatinine elevated to 1.6 (1 point). INR is 1.7 on Coumadin, will discuss with pharmacy regarding dose and monitoring (this is monitoring of a high risk drug and fulfills the criteria for high risk)
4 data points already and high risk demonstration, theoretically the note can stop here and the 99233 criteria have been fulfilled, we have 2 out of the 3 needed, we skipped the exam here remember.
Plan
IV diuresis, hold ACE, order echo, monitor renal function
This note was very very short, but still met the requirement in terms of points needed, essentially its highly point system based and despite the brevity of the note fulfills the documentation needs for a 99233.