What is the Medicare reimbursement for a 99223 (Current Procedural Terminology) code?

Medicare Reimbursement for CPT Code 99223

Medicare reimburses CPT code 99223 (Initial Hospital Care) based on a predetermined fee schedule that varies by geographic location, with the national average payment rate determined annually by the Centers for Medicare and Medicaid Services (CMS). 1

Understanding CPT Code 99223

CPT code 99223 represents the highest level of initial hospital care for a new or established patient, which includes:

• A comprehensive history and physical examination 1
• Medical decision-making of high complexity 1
• Typically requires 70 minutes of face-to-face time with the patient 1

Medicare Payment Structure

Medicare payment for 99223 follows these principles:

• Reimbursement is based on the Medicare Physician Fee Schedule (MPFS) 1
• Payment rates vary by geographic location due to regional cost differences 1
• The fee consists of three components:
  • Physician work (time and intensity) 1
  • Practice expense (overhead costs) 1
  • Professional liability insurance 1

Billing Requirements

To receive proper Medicare reimbursement for 99223, providers must:

• Document a comprehensive history and physical examination 1
• Demonstrate high-complexity medical decision making 1
• Use proper documentation to support the level of service billed 2
• Submit claims using the CMS-1500 form 1

Telemedicine Considerations

If providing this service via telemedicine:

• Use modifier "95" to indicate services provided via telemedicine 1
• Ensure an interactive audio and video telecommunications system that permits real-time communication 1
• Verify the patient is at an authorized originating site 1
• Confirm you qualify as an authorized distant site practitioner 1

Common Pitfalls to Avoid

• Upcoding: Billing for a higher level of service than documented can lead to audits and penalties 2
• Insufficient documentation: Failure to document all required elements for 99223 may result in downcoding or claim denial 2
• Geographic variations: Not accounting for payment differences based on practice location 1
• Missing modifiers: Failing to use appropriate modifiers for special circumstances (like telemedicine) 1

Financial Impact

• Medicare payment for inpatient services like 99223 is generally lower than the actual provider costs, creating a "reimbursement gap" 1
• Studies show that Medicare payments for evaluation and management services often do not fully cover the costs of providing comprehensive care 1
• The reimbursement rate may be affected by Medicare payment policy changes and annual fee schedule updates 3, 4

For the most current specific payment amount for CPT code 99223 in your geographic area, providers should consult the current Medicare Physician Fee Schedule published by CMS.