CPT 99233: Subsequent Hospital Care - High Complexity
Subsequent hospital care visit with high complexity medical decision making for unstable or significantly deteriorating patients.
Documentation Requirements
- Interval history with clinical changes since last note
- High complexity medical decision making
- Focused examination with attention to unstable systems
- Updated assessment reflecting deterioration or instability
- Revised treatment plan addressing new findings
Billing Tips
- High MDM — patient unstable, deteriorating, or requires significant care changes
- Document clinical instability or significant complication
- Include independent interpretation of new diagnostic data
- High-risk treatment decisions (escalation of care, new IV drugs)
- Distinguish from 99232 by documenting severity of change
Frequently Asked Questions
When should I use 99233 instead of 99232?
99233 is for patients who are unstable, significantly deteriorating, or require major treatment changes. 99232 is for stable patients with moderate MDM. Scribeable identifies acuity indicators to support the correct level.
How does Scribeable help with hospital rounding notes?
Scribeable captures your rounding discussions and generates compliant progress notes with interval history, updated assessments, and treatment plans — supporting accurate 99232 or 99233 billing.