CPT 99231E&M

Sbsq hosp ip/obs sf/low 25

CPT 99231 is billed when a doctor provides a follow-up visit to a hospitalized patient whose condition is stable or improving and requires straightforward medical decision-making.

Showing rates for

National Average

Base Medicare rate

$47.23

This calculator gives a typical-case estimate using standard Medicare modifier rules. Actual payment depends on payer policies, documentation, code-specific CMS status indicators, and locality. Verify before billing.

RVU breakdown

Work RVU

PE RVU (NF)

0.38

MP RVU

0.08

Total RVU

1.46

Conversion factor: 32.3465 · Source: CMS MPFS RVU25A · Confidence: High

NCCI bundling edits

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Billing tips

Ensure medical decision-making meets straightforward criteria: minimal diagnosis/treatment options, minimal data review, and minimal risk. Upcoding to 99232 without proper documentation risks audit.
Impact: Proper level selection prevents denials and recoupments; difference between 99231 ($47.23) and 99232 (~$72) must be justified
Document time when it drives code selection (95+ minutes total time on date of encounter allows 99233). For 99231, time-based coding rarely applies as MDM typically determines level.
Impact: Time-based coding can increase reimbursement on prolonged encounter days but requires meticulous time documentation
Bill only once per date of service per physician or same-specialty group. If multiple encounters occur, combine into single note with highest appropriate level.
Impact: Duplicate billing results in 100% denial of second claim; proper consolidation ensures full payment
For split/shared visits with NPPs, ensure both providers document their portions and the physician performs substantive portion to bill under physician NPI.
Impact: Incident-to does not apply to hospital billing; split/shared allows 100% physician rate versus 85% NPP rate, saving approximately $7 per encounter
Verify patient status (inpatient vs. observation) matches medical record; 99231-99233 apply to both but patient status affects hospital facility billing.
Impact: Status misalignment triggers audits; while physician payment is same ($47.23), incorrect status documentation creates compliance risk
Do not bill 99231 on discharge date; use 99238-99239 for discharge day management instead, which have higher reimbursement.

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Frequently asked questions

What is the difference between CPT 99231 and 99232?

CPT 99231 requires straightforward medical decision-making for stable patients, while 99232 requires moderate complexity decision-making for patients with new or progressing problems. 99232 reimburses at approximately $72 compared to $47.23 for 99231, reflecting the increased complexity and physician work.

How much does Medicare pay for CPT 99231 in 2025?

Medicare pays $47.23 for CPT 99231 in 2025 based on the national average rate. This rate applies to both facility and non-facility settings. The total RVU is 1.46 multiplied by the 2025 conversion factor of 32.3465.

Can CPT 99231 be billed for observation patients?

Yes, CPT 99231 is appropriate for both inpatient and observation status patients receiving subsequent hospital care. The descriptor specifically states 'subsequent hospital inpatient or observation care' and the reimbursement is identical regardless of patient status.

How many times can you bill 99231 for the same patient?

You can bill 99231 once per day for each date of service the physician provides subsequent hospital care. There is no limit to the number of consecutive days, but only one provider from the same specialty and group practice can bill per date. Do not bill 99231 on admission day (use 99221-99223) or discharge day (use 99238-99239).

What documentation is required for CPT 99231?

Documentation must include a medically appropriate history/examination, straightforward medical decision-making (minimal problems addressed, minimal data reviewed, minimal risk), assessment of patient status, and treatment plan. The 2021 E/M guidelines focus on medical decision-making or time rather than detailed history and exam components.

Can a nurse practitioner bill CPT 99231?

Yes, nurse practitioners and physician assistants can bill 99231 for subsequent hospital care within their scope of practice and state regulations. They receive 85% of the physician fee schedule amount unless billing as a split/shared service with a physician who performs a substantive portion, which allows billing at 100% under the physician's NPI.

What is the RVU value for CPT code 99231?

CPT 99231 has a total RVU of 1.46 in 2025, consisting of 1.0 work RVU, 0.38 practice expense RVU, and 0.08 malpractice RVU. These values are the same for both facility and non-facility settings. When multiplied by the 2025 conversion factor of 32.3465, this equals the Medicare payment of $47.23.