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Level 1 Hospital Progress Note (99231)

The 99231 represents the lowest level of care for hospital progress notes.  This is the least common level of care selected by internists who used the 99231 for only 5.17% of these encounters in 2018.   The reimbursement for this level of care is approximately $40 and it is worth 0.76 RVUs.  Usually the patient is stable or improving.

Documentation requires TWO out of THREE of the following :

1)  Problem Focused History
2)  Problem Focused Exam
3)  Straightforward / Low Complexity Medical Decision-Making

Or 15 minutes spent face-to-face with the patient if coding based on time.  The appropriate documentation must be included.

Clinical Example

This topic is covered in much more detail in of one of our web-based E/M coding courses.

Hospital Progress Notes

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Basic Course Preview
These are the most common hospital encounters. Most doctors over-document and under-code for these services. This course will show you how to avoid this trap and save time while increasing reimbursement.    
  For mutliple users, consider an E/M Compliance Web Portal.


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