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)
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
NCCI Exclusions
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
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
CMS Eligibility: Patient is stable or recovering. Duration of stay
Target Specialties & Utilization
Typical Clinical Indications (ICD-10)
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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