CPTCodeCalculator
E/MBase2026 Compliant

CPT 99231

2026 Billing Guide

Subsequent Hosp Care, Low

Reimbursement

$37.07

Threshold

25m

2026 Status

Active

What is CPT Code 99231?

CPT 99231 is defined as: Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level medical decision making. Represents daily rounds for stable patients.

This code is primarily used for E/M services. It falls under the category of Hospital Inpatient/Observation & Emergency Department and is valid for the 2026 calendar year according to the CMS Physician Fee Schedule.

2026 RVU Components

Relative Value Units (Non-Facility)

Standard Formula Applied

Work RVU

0.8

Physician Effort

PE (Non-Fac)

0.25

Practice Expense

Malpractice

0.06

Risk Factor

Total RVU

1.11

Note: [(Work RVU * Work GPCI) + (PE RVU * PE GPCI) + (MP RVU * MP GPCI)] * Conversion Factor

2026 CMS Policy Intelligence

hospitalist baseline

Maintains the standard valuation for daily professional rounding.

efficiency shield

Exempt from -2.5% efficiency cut.

site of care

Used for both inpatient stays and extended observation stays beyond the first 24 hours.

Administrative Framework

Global Period

000

Place of Service

21 (Inpatient Hospital)22 (On Campus-Outpatient Hospital - Observation)

NCCI Exclusions

Do not bill with:99221-99223 (mutually exclusive on same day)99238-99239 (mutually exclusive on same day)

Required Primary Codes

Must be billed alongside a primary service.

Operational Requirements

minimum time

25 minutes (if billing by time)

staff type

Physician or other Qualified Health Care Professional (QHP)

frequency

Once per day per specialty

add on codes

care plan requirement

Documentation of patient progress or stability; low-level MDM.

Compliance Checklist

Update on clinical status
Straightforward/low MDM OR 25+ minutes
Review of daily labs/vitals
Coordination of ongoing inpatient care

Audit Defense

No specific audit defense elements defined.

2026 Update

Medicare is using NLP to detect 'cloned notes' in subsequent hospital visits; ensure unique daily assessment content.

Common Clinical Scenarios

Follow-up for a patient on day 3 of IV antibiotics who is now afebrile
Daily rounding on a post-operative patient meeting recovery milestones

CMS Eligibility: Patient is stable or recovering. Duration of stay

Target Specialties & Utilization

Internal MedicineHospitalistsGeneral Surgery

Typical Clinical Indications (ICD-10)

Z48.89 (Other postprocedural aftercare)J18.9 (Pneumonia, status improving)

Billing Differentiation

VS 99221

99221 is the INITIAL day; 99231 is any day AFTER the initial visit.

VS 99232

99232 is for moderate MDM (35m).

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