CPT code 99223: Initial hospital visit, high decision making or 75 minutes2026 Medicare rate & RVUs in Illinois
Report an initial inpatient or observation evaluation when the practitioner performs high-complexity medical decision making or spends at least 75 minutes on the encounter date.
CMS doesn’t publish an office rate for 99223 in Illinois.
Medicare allowed amount for participating (non-QP) physicians, before deductible, coinsurance and claim adjustments. Not a patient’s bill or a hospital charge.
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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 in Illinois
The same RVUs, adjusted for each area’s costs. Open a locality for its calculation, history and nearby areas.
| Payment locality | Office | Facility |
|---|---|---|
| Chicago, IL | Unavailable | $169.40 |
| East St. Louis, IL | Unavailable | $163.39 |
| Rest of Illinois | Unavailable | $158.97 |
| Suburban Chicago, IL | Unavailable | $165.17 |
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.
How the rate is built · 99223
RVUs × geographic indexes × conversion factor
Work3.50
3.50 RVUs× 1.000 GPCI
Practice expense0.90
0.90 RVUs× 1.000 GPCI
Malpractice0.28
0.28 RVUs× 1.000 GPCI
Adjusted RVUs
4.6800
Conversion factor
$33.4009
Medicare rate
$156.32
Every GPCI starts at 1.000, the national rate. Enter a ZIP or drag a slider.
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.
Place of service · 99223
Which rate does Medicare pay?
The POS code on the claim line (CMS-1500 box 24B).
POS 11 · non-facility rate · national
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99223 isn’t priced in this setting.
99223 compared with similar codes
Compare codes · National
5 codes, side by side
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.
99223 billing questions
Can a consulting specialist report 99223 for a Medicare patient?
Yes, if the specialist's initial inpatient or observation evaluation meets the high medical decision-making or 75-minute criterion. Medicare does not recognize inpatient consultation codes; a specialist who is not the principal physician of record does not append modifier AI.
Who appends modifier AI?
The principal physician of record appends AI to the initial hospital care code for Medicare. Other practitioners reporting an initial hospital evaluation do not append it.
How is time beyond 75 minutes reported?
Medicare uses G0316 with a time-selected 99223 once its prolonged-service threshold is met; reaching 75 minutes alone does not support the add-on. Payers following CPT prolonged-service rules may use 99418 under its applicable threshold.
Should 99223 or 99236 be used when admission and discharge occur on the same date?
For Medicare, a stay of at least eight hours may qualify for a same-date admission and discharge code. Select 99236 only if its high-level decision-making or time criterion is met; for a shorter stay, select an initial hospital care code at the supported level.
Can an ED visit and 99223 be billed on the same date?
An ED encounter by the same practitioner that leads to admission is incorporated into the initial hospital care service. A separate emergency physician may report the ED service.
Does 99223 apply to observation patients?
Yes. The initial hospital care series covers both inpatient and observation stays.
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
Show the CMS file lines behind this rate
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