CPT code 99223: Initial hospital visit, high decision making or 75 minutes2026 Medicare rate & RVUs

Medicare pays $156.32 for 99223 nationally in a facility.

Medicare allowed amount for participating (non-QP) physicians, before deductible, coinsurance and claim adjustments. Not a patient’s bill or a hospital charge.

What 99223 covers

This initial inpatient or observation evaluation may be performed by a hospitalist, admitting internist, or other physician or qualified health care professional seeing the patient during the stay. High-level decision making may arise with acute respiratory failure requiring decisions about intensive monitoring or severe sepsis requiring treatment escalation; the diagnosis alone does not establish the level. For Medicare patients, specialists asked to evaluate a patient during the stay select an initial hospital care code rather than an inpatient consultation code.

Select 99223 when medical decision making is high in at least two of the three elements—problems, data, and management risk—or qualifying practitioner time reaches 75 minutes on the encounter date. Document the assessment and management decisions or total time, which may include record review and documentation but excludes separately billed work. For Medicare, only the principal physician of record appends modifier AI. When the applicable prolonged-service threshold is met, Medicare uses G0316 with a time-selected 99223; payers following CPT prolonged-service rules may use 99418. An earlier same-day office or emergency visit by the same practitioner that leads to admission is incorporated into the hospital visit.

This summary was written with AI assistance from CMS physician fee schedule data and checked against the CMS billing rules shown here. Rates on this page come directly from CMS files.

Where 99223 pays more and less

The same RVUs, adjusted for each area’s costs. Open a locality for its calculation, history and nearby areas.

109 of 109 payment localities

99223 rates by state

Office rate range in each state. Select a state to see its payment localities.

How the 99223 rate is calculated

Each of 99223’s three RVUs is multiplied by a geographic index (GPCI) for the payment locality, added up, and multiplied by the conversion factor. Drag the indexes or enter a ZIP to see what moves the rate.

Payment rules and modifiers for 99223

99223 has no global surgery period, no multiple-procedure, bilateral or assistant-at-surgery adjustment, and no professional/technical split. What changes the payment is where the service happens: the place of service on the claim decides whether Medicare pays the office or the facility rate.

99223 compared with similar codes

How to choose

99233Hospital follow-up visitSubsequent day, high complexity

99223 is initial inpatient or observation care; 99233 is high-level subsequent care after the practitioner's initial service during the stay.

99222Initial hospital visitModerate MDM or 55 minutes

Choose 99222 for moderate medical decision making or at least 55 minutes of qualifying time. Choose 99223 for high medical decision making or at least 75 minutes.

99236Hospital careSame-date admission and discharge

99236 covers high-level admission and discharge care on the same date when the stay meets Medicare's eight-hour requirement. A shorter same-date stay may be reported with 99223 if its level is supported.

99255Inpatient consultationHigh level

99255 is an inpatient or observation consultation code for payers that recognize consultations. For Medicare, select an initial hospital care code, including 99223 only when its decision-making or time criterion is met.

Codes related to 99223

Related codes aren’t interchangeable: bill the code that matches the service performed.

Where these rates come from

FeeBase calculates base physician payments from CMS work, practice-expense and malpractice RVUs, adjusted by each locality’s geographic indexes and the conversion factor. Services without a published rate are labeled, never given a made-up amount. Amounts are Medicare allowed amounts before claim adjustments: not a patient’s bill or a commercial rate.

CMS RVU26D · effective Oct 1, 2026 through the day before Jan 1, 2027

Open CMS sourceHow we calculate rates