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    v1.0.30
    OpenPayerBilling CodesSubsequent Hospital Inpatient or Observation CareCPT cpt-99233-subsequent-hospital-care-high-complexity
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    CPT 99233: Subsequent Hospital/Observation Care, High MDM or 50 Minutes

    Medicare pays $109 and commercial payers pay $127 on average nationally for this procedure.

    CPT code 99233 denotes a subsequent hospital inpatient or observation evaluation and management (E/M) visit provided on a single date when the encounter involves high-complexity medical decision making or when the provider documents at least 50 minutes of total time; this service is classified as subsequent hospital/observation care and is typically furnished in an inpatient hospital or observation unit for ongoing management of an admitted patient.

    For related coverage guidance, see recent payer policy updates: Automated Ambulatory Blood Pressure Monitoring for Diagnosis of Hypertension in Patients with Elevated Office Blood Pressure, Cardiology - Ivabradine, Cardiac Computed Tomography (CCT)/Coronary Computed Tomographic Angiography (CCTA).

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    National Reimbursement Benchmarks

    Medicare's mean rate for CPT 99233 sits at $109.10, below the BUCA (average commercial) mean of $126.50, indicating a modest commercial uplift relative to the federal program. Cigna and Aetna show higher central tendencies (means of $165.40 and $140.80 respectively), while UnitedHealth Group and Blue Cross Blue Shield center lower than many commercial peers, reinforcing a mixed commercial landscape with Medicare near the lower-middle of national averages.

    Dispersion measured as the interquartile range (P75 minus P25) is widest for Cigna at $104.60 and Aetna at $90.40, reflecting greater variability in negotiated commercial payments. UnitedHealth Group is the tightest at $45.60, with Blue Cross Blue Shield also relatively constrained at $45.60. BUCA's IQR is $60.50 and Medicare's IQR is $5.00, showing Medicare payments are much more compressed than most commercial payers.

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    National Payer Mean Reimbursement Rates

    State Reimbursement Rates

    State: Alaska1 / 51

    Rate by payer

    Clinical & Coding Specifications

    Clinical Context

    A 68-year-old male inpatient admitted to a general medical ward under the care of a hospitalist for community-acquired pneumonia (J18.9) with a history of essential hypertension (I10) and type 2 diabetes (E11.9). He was started on intravenous antibiotics and supplemental oxygen. On hospital day three the patient develops new urinary frequency and fever (R50.9), and a urinalysis is suggestive of a urinary tract infection (N39.0). The hospitalist performs a comprehensive daily evaluation: reviews interval history since the prior visit, performs an expanded problem-focused to detailed examination, reviews laboratory and imaging results (chest radiograph and repeat labs), adjusts the antibiotic regimen, coordinates consultation with primary care and infectious disease as needed, and documents discussions with family about plan and prognosis.

    This encounter qualifies as a subsequent inpatient visit with high medical decision making or at least 50 minutes total time spent on the date of service, and is billed as 99233. Typical workflow includes review of overnight events and telemetry/monitoring data, focused re-examination, medication reconciliation, diagnostic test review, documentation of complex decision making (e.g., antibiotic changes, management of comorbid diabetes and hypertension), and care coordination for discharge planning or escalation of care.

    Related CPT Codes

    CPT Code

    Related Modifiers

    11 rows

    ModifierDescriptionWhen to Use
    25CPT modifier 25 indicates that on the same day as another procedure or service, the same physician or other qualified health care professional provided a significant, separately identifiable…- When to apply: Use modifier 25 only on an E/M code to indicate the same provider delivered a significant, separately identifiable E/M service on the same day as another procedure or service — i.e.,…
    57CPT® modifier -57 (“Decision for Surgery”) is appended to an Evaluation and Management (E/M) service when that encounter results in the initial decision to perform a major surgery (a procedure with a…- Use modifier 57 when an E/M service provided by the same provider (or same tax ID) on the day of or the day before a major surgical procedure (90‑day global period) results in the initial decision…
    59Modifier 59 indicates a distinct procedural service when two procedures that are not normally billed together are clinically and procedurally separate. The CPT definition (as reiterated by CMS)…- Use modifier -59 to report a distinct procedural service when documentation supports that the procedure reported is not normally billed together with another service on the same day because of a…
    24Modifier 24 denotes an unrelated evaluation and management (E/M) service performed by the same physician or qualified healthcare professional during a postoperative global period. Per CPT guidance,…- Use modifier 24 when you report an evaluation and management (E/M) service performed by the same physician or same-specialty group during a procedure’s postoperative global period that is unrelated…
    26Modifier 26 (Professional Component) identifies and bills only the professional portion of a split service — the physician’s interpretation, report, and medical judgment — when the technical…- Use CPT Modifier -26 when you are billing only the professional component (PC) of a split‑bill eligible service—i.e., you performed the physician interpretation, medical judgment and prepared a…
    52Modifier ‑52 (Reduced Services) indicates that a service or procedure was partially reduced or omitted at the provider’s discretion, allowing reporting of the basic procedure number with a qualifier…- Use modifier -52 when a physician or qualified health professional electively reduces or omits part of a procedure or service (for example, performing fewer required views or omitting a portion of…
    53Modifier 53 (Discontinued Procedure) signals that a surgical or diagnostic service was begun by the physician but terminated because of extenuating circumstances that threatened the patient’s…- Use modifier -53 when a physician/qualified healthcare professional has started a surgical or diagnostic procedure (e.g., anesthesia administered, incision or scope insertion) and then discontinues…
    22Modifier –22 (Increased Procedural Services) is used when a reported procedure is substantially more extensive than normally required. The CPT Manual and CMS state it may be appended only when the…- When to use: Append modifier -22 to a procedural CPT code when the service performed is substantially more extensive than the usual service described by that code — i.e., the procedure required…
    95Modifier 95 indicates that a service was provided via synchronous, real‑time audio‑video telehealth rather than in‑person. Per CMS, AAPC and professional associations, append modifier 95 to claim…- Use modifier 95 to indicate a service was furnished via synchronous, real‑time audiovisual telehealth (a live audio‑video conference between patient and provider) rather than in‑person. - Pair…
    76Modifier -76, Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional, is appended when the same provider performs an identical, medically necessary procedure or…- Use modifier -76 when the same physician or other qualified health care professional performs an identical procedure or service a second (or subsequent) time on the same date of service and the…

    Showing 1–10 of 11

    Related Provider Taxonomies

    8 rows

    Taxonomy Code
    208M00000X
    207R00000X
    208D00000X
    207ZF0201X
    252Y00000X
    261QX0100X
    207VM0101X
    207PH0002X

    Related Payer Policy Updates

    Specialty: Cardiology1 / 3

    10 rows

    PolicyPayerEffective Date
    Automated Ambulatory Blood Pressure Monitoring for Diagnosis of Hypertension in Patients with Elevated Office Blood PressureBluecross Idaho2026-11-01
    Cardiology - IvabradineCigna2026-10-15
    Cardiac Computed Tomography (CCT)/Coronary Computed Tomographic Angiography (CCTA)univerahealthcare2026-10-15
    Percutaneous Ventricular Assist DeviceUnitedHealthcare2026-10-01
    Cardiovascular Disease Risk AssessmentOscar Health2026-10-01
    Biomarkers for Myocardial Infarction and Chronic Heart FailureOscar Health2026-10-01
    Multiple Procedure Payment Reduction for Diagnostic Cardiovascular ProceduresBlue Cross Blue Shield - Maine2026-10-01
    Left Atrial Appendage Closure Devicesexcellus_health_plan_inc2026-09-17
    Left Atrial Appendage Closure Devicesuniverahealthcare2026-09-17
    Cardiac Omnibus CodesCigna2026-09-15

    Related Codes

    CPT-99231-SUBSEQUENT-HOSPITAL-INPATIENT-OBSERVATION-CARE-LOW-MDM-25MIN

    CPT 99231: Subsequent Hospital Inpatient or Observation Care, Low Complexity

    CPT-99232-SUBSEQUENT-INPATIENT-OBSERVATION-MODERATE-COMPLEXITY

    CPT 99232: Subsequent Hospital/Inpatient or Observation Care, Moderate Complexity

    Frequently Asked Questions

    References

    1. 1.CPT® Codes and Descriptions. AAPC. Retrieved Aug 11, 2026.Maintains the CPT code set's official descriptions and guidelines, licensed from the American Medical Association, used as the definitional source for CPT codes on this page.
    2. 2.HCPCS Quarterly Update. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's quarterly release of HCPCS Level II codes and short/long descriptors, the source for HCPCS code definitions and update history.
    3. 3.ICD-10-CM Full Code List. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's complete ICD-10-CM diagnosis code list, used to cross-reference diagnosis codes associated with this procedure or service.
    Published by

    Trek Health powers OpenPayer with a leading commercial payer intelligence platform, seamlessly converting fragmented payer data into actionable insights for provider organizations.

    Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

    Description
    Relationship to This Procedure
    99231Subsequent hospital care, per day; problem focused or straightforward/low complexity MDMLower-level subsequent inpatient visit when MDM is straightforward or time is shorter than required for 99233
    99232Subsequent hospital care, per day; expanded problem focused or moderate complexity MDMMid-level subsequent inpatient visit when MDM is moderate and/or time is less than threshold for 99233
    99238Hospital discharge day management; 30 minutes or lessUsed when the patient is discharged and the physician documents discharge management up to 30 minutes, often following serial 9923x visits
    99239Hospital discharge day management; more than 30 minutesUsed for complex discharge planning requiring more than 30 minutes, typically following high-MDM inpatient care such as 99233