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Level 3 Hospital Progress Note (99233)

The 99233 represents the highest level of care for hospital progress notes.  This is the second most popular code selected by internists who used the 99233 level of care for about 35% of these encounters in 2018.  The Medicare allowable reimbursement for this level of care is approximately $106 and it is worth 2.0 RVUs.  Usually the patient is unstable or has developed a significant complication or a significant new problem.

The documentation for this encounter requires TWO out of THREE of the following :

1)    Detailed History
2)    Detailed Exam
3)    High Complexity Medical Decision-Making

Or 35 minutes spent face-to-face with the patient if coding based on time.  The appropriate documentation must be included.

Clinical Example 1
Clinical Example 2

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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