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Unlike CPT 2026, the update does not change CPT code 99223 which continues to describe high-complexity starting hospital inpatient or observation care. The code should be reported by providers with high levels of medical judgment (or total time, if at least 75 minutes). Documentation must be accurate, you need to know the reimbursement changes, and understand the new E/M elements. In 2026, nothing is without plan: compliance, billing right and reimbursed in full.
For health care providers, staying current with changes to the CPT code set is essential for accurate billing, optimal reimbursement, compliance with payer requirements, and quality documentation. One of the most widely used Evaluation and Management (E/M) codes in hospital medicine is CPT code 99223, which is used to report a high-complexity initial hospital inpatient or observation care visit. As the 2026 CPT code set takes effect on January 1, 2026, it’s important for clinicians, coders, and billing professionals to understand what, if any, changes impact this code and how to prepare to implement them.
.Understanding CPT Code 99223 Before 2026
One of the E/M codes for hospital inpatient and observation care is CPT code 99223. It describes a new or existing patient’s initial hospital inpatient or observation treatment that involves a significant amount of medical decision-making or a predetermined amount of time. In practice, this code is commonly used for complicated admissions where the physician does a full evaluation, makes a complicated plan, and spends a lot of time coordinating care, making decisions, and writing down what happened.
In the past, code selection for this service could be based on a detailed history and physical exam. But now, CMS and CPT stress medical decision making (MDM) and total time on the date of service are the main factors for choosing the right E/M code level. These changes, which were made to E/M codes in 2023, are still affecting how providers document and report 99223 services in 2026.
What CPT 99223 Represents in Clinical Billing?
Generally intended to depict difficult clinical conditions, 99223 is the highest level of first E/M care in the hierarchy of hospital E/M codes. When a patient’s clinical condition necessitates a thorough evaluation, substantial medical decision-making, or a high level of care coordination, providers usually use this code. The code descriptor requires that either a “high level of medical decision making” be present or that at least 75 minutes total time be spent on the encounter during the date of service.
This distinction is important because time-based reporting allows clinicians to count total care activity. For example, reviewing records, coordinating care with consultants, documenting the encounter, and communicating with family or caregivers—not just face-to-face time at the bedside. As a result, many providers find that 99223 appropriately reflects their work when comprehensive care is provided, especially in complex cases where high cognitive effort is a major component of care.
Updates to the 2026 CPT Code Set
In contrast to certain parts of the CPT 2026 update that bring in new codes or retire outdated versions, 99223 exists as it is in the 2026 CPT code set. The American Medical Association (AMA) didn’t rescind, carve out or substantially alter this code for 2026 either. Instead, much of the 2026 update’s attention has been on adding new codes for care in other service lines like digital health services, remote physiologic monitoring and AI-enabled diagnostics and refining guidelines that accompany the overall E/M code structure.
While the 99223 code remains unchanged, how and when it’s used has evolved. The revision of E/M guidelines by the AMA in recent years has removed the rigid requirement for both detailed history and physical examination to be documented as separate elements, but rather criteria based on MDM or total time can be met. These same tenets, a byproduct of the overhaul in 2023, continue to serve as our reporting rules for 99223 in 2026 and beyond.
Key Considerations for 99223 Billing in 2026
Documentation and Medical Decision Making
In 2026, documentation is still very important for choosing CPT 99223. When choosing this code, the physician must write down enough information to support the highest level of complexity. This comprises thorough documenting of clinical findings, diagnostic reasoning, the intricacy of problems addressed, the amount and complexity of data evaluated, risk of complications or morbidity, and clinical judgment that supports a high degree of MDM.
Even though the history and physical exam parts are less strict than they used to be, the paperwork still needs to show that the clinician did a medical evaluation that was acceptable for the care given and that this assessment is correctly shown in the code level chosen.
Reporting Based on Time
Time remains an option for code selection when MDM alone does not dictate selecting a specific E/M level. With regard to 99223, the total time on the date of service must be at least 75 minutes. Given that EHR systems are recording detailed timestamps of events and activities, clinicians/coders should continuously check time stamps against their documentation to ensure accuracy, avoid undercoding and reduce claim denials.
Changes to Reimbursement for 2026
The code descriptor for 99223 stays the same, however the amounts paid for it may change significantly because the Physician Fee Schedule is updated every year. For instance, estimates for the national average Medicare reimbursement for CPT 99223 in 2026 are around $156.31 for services that don’t take place in a facility.
Interaction With Additional 2026 CPT Modifications
It’s also important to remember that the E/M environment as a whole is still changing, even though 99223 has not. Numerous new codes in areas including digital health services and remote physiologic monitoring (RPM) are included in CPT 2026. These codes may relate to inpatient care when patients move between venues or when clinical decision-making is influenced by telemonitoring. Providers can identify chances for correct reporting and reimbursement along the continuum of treatment by keeping up with these changes.
Providers should also be aware of payer rules covering E/M services. Even though CPT codes and descriptors are required to be uniform, the adjudication of claims that include 99223 may still be swayed by a payer’s specific documentation or interpretation of MDM factors.
Strategies to Prepare for 2026
The 2026 CPT coding year is a time for clinical and administrative staff to come together in tandem. To ensure that the documentation does indeed drive code selection, providers will be educated on how to accurately document MDM and time. To match clinical notes with the right code level, coders will need training in the latest CPT and compliance criteria. The billing cycle, for example, can implement audit tools and quality checks to catch any coding problems early.
Best practices can even be embedded into EHR templates and workflow modifications in a way that will enable providers to exhibit common sense documentation at the point of service in order to remain compliant. Finally, to address difficult cases, especially in complex inpatient settings, coders and physician leaders should participate in continued coding roundtables either via webinars or professional society venues.
Final Thoughts
With the implementation of 2026 CPT code set in January 2026, CPT code 99223 will remain an integral part of hospital inpatient E/M coding. Although there haven’t been significant changes to the code itself, what this requires of providers is that we carefully focus on the bigger picture within E/M documentation, coding rules that push more for MDM and time, and how reimbursement will take shape. Compliance, correct payment and an accurate reflection of the clinical work done for patients can all be provided by understanding how to correctly document, bill and support such a level of care. Providers will be successful in managing CPT 99223 in the evolving health care environment by preparing for 2026 as soon as possible, adhering to newly updated coding guidelines, and ensuring that clinical documentation aligns with payer expectations.
Make An Appintment With A2ZFAQs
CPT code 99223 is used to report initial hospital inpatient or observation care involving a high level of medical decision making or when the provider spends at least 75 minutes on the patient’s care on the date of the encounter. It reflects complex patient evaluations and care planning.
No, the 2026 CPT code set does not include any changes, deletions, or replacements for CPT code 99223. Nonetheless, physicians must continue to adhere to the most recent Evaluation and Management (E/M) criteria, which are based on total time or medical decision making.
High Level Medical Decision Making must be present in the documentation, or it should clearly show that 75 minutes or more was spent on the day of service. Assessment, diagnosis review, care coordination and treatment planning should all appear in the record.
Yes, if the encounter is 75 minutes or more; the physician can bill CPT code 99223 based on the total time for that day. This encompasses face-to-face and nonelectronic (eg, telephone) care activities.
The CPT itself does not change, but payment may vary with changes in the Medicare Physician Fee Schedule and payer-specific adjustments. The specific amounts of payment need to be derived by reviewing payer contracts.