First hospital inpatient or observation visit by a given physician that requires high medical decision making or at least 75 minutes of total time on that date.

3 sources ↓

Medicare: $156.32
Work RVU: 3.5
Global, days
Region: General

Drawn from CMS

Documentation requirements

What must appear in the operative or office note to support the claim.

Source · Editorial brief grounded in 3 cited references ↓

History and exam for the admitting or consult problem
High-complexity MDM: severity, data reviewed (imaging, labs), and high-risk decisions such as surgery in a patient with major risk factors
Explicit decision for surgery when billing with modifier 57
Total time on the date if time is used
Who requested the consult, if not the admitting physician

Applicable modifiers

Modifiers commonly billed with this code.

Source · AMA CPT modifier descriptors · CMS NCCI Policy Manual

57 Decision for surgery AI Modifier 25 Significant separate E/M FS Modifier

What this code covers

Source · Editorial summary grounded in 3 cited references ↓

99223 reports the first inpatient or observation encounter by a physician when decision making is high, or total time on the date reaches 75 minutes. For orthopedic surgeons, the typical case is an elderly hip fracture admission with anticoagulation, cardiac risk, and a same-day or next-day decision for surgery.

Medicare does not pay inpatient consultation codes, so a consulting orthopedist reports the initial hospital code instead. The admitting physician adds modifier AI so Medicare can tell the attending from consultants.

The global surgery rules matter here. If this visit is where the decision for major surgery is made, on the day of or day before a 90-day procedure, add modifier 57. Without it, the visit bundles into the surgery. If surgery was already planned and the visit is just a preop check, it is part of the global and not separately billable.

RVU & reimbursement

Component RVUs and Medicare national rate. Actual payment varies by GPCI locality.

Source · CMS Physician Fee Schedule, RVU26A · January 2026

Work RVU vs. total RVU

The work RVU (3.5) is the surgeon's own effort — the figure physician pay and productivity targets are built on. The total RVU (4.68) adds practice overhead and malpractice, and is what drives the Medicare payment below.

Work RVU	3.5
Practice expense RVU	0.9
Malpractice RVU	0.28
Total RVU	4.68
Medicare national rate	$156.32
Global period	days

Payment by site of service

Medicare pays different rates by setting. HOPD typically pays substantially more than ASC for the same procedure.

Source · CMS OPPS Addendum B·ASC HCPCS payment rates·2026

Setting	Medicare rate (national)
Office (PFS non-facility) Procedure performed in physician's office	$156.32

Common denial reasons

The recurring reasons claims for CPT 99223 get rejected.

Source · Editorial brief grounded in CMS NCCI edits, AAOS coding appeals, and cited references ↓

Decision for surgery visit billed without modifier 57 and bundled into the global
Billed when the surgery was already scheduled and the visit was a routine preop check
MDM documentation supports only moderate complexity
Two physicians of the same specialty in the group both billed an initial visit
Consult code billed to Medicare instead of an initial hospital code

Frequently asked questions

Source · Generated from the editorial pipeline, verified against 3 cited references ↓

01Can an orthopedic consultant bill 99223 to Medicare?

Yes. Medicare does not pay consult codes, so consultants bill 99221 to 99223 for the first inpatient visit. Only the admitting physician adds modifier AI.

02When do I use modifier 57 with 99223?

When this visit results in the decision to perform major surgery (90-day global) on the same day or the next day.

03Does 99223 apply to observation patients?

Yes. Since 2023 the initial hospital codes cover both inpatient and observation status.

04What time is required for 99223?

At least 75 minutes of total time on the date of the encounter when coding by time.