Correct use of inpatient CPT® codes is essential for documenting medically necessary care, ensuring proper reimbursement, and maintaining regulatory compliance. In 2025, inpatient coding continues to follow the modern Evaluation & Management (E/M) framework that emphasizes medical decision-making (MDM) and total time, replacing outdated documentation rules that relied heavily on exam and history elements.

This article provides a clear overview of inpatient CPT codes in 2025, how they are selected, what documentation they require, and common best practices for accurate and compliant coding.

1. Overview of Inpatient E/M CPT Codes in 2025

Inpatient E/M codes are divided into three major categories:

1. Initial Hospital Care (Inpatient Admission)

Used once per inpatient stay by the admitting physician or physician group that assumes responsibility for the patient’s care.

2. Subsequent Hospital Care (Daily Inpatient Visits)

Used for day-to-day management after admission.

3. Hospital Discharge Services

Used on the day the physician completes the discharge process.

These codes are selected based on either:

• The complexity of medical decision-making (MDM)

OR

• Total time spent on the date of the encounter

This flexibility allows clinicians to document accurately based on the true work performed.

2. Initial Hospital Care (Inpatient Admission)

Initial hospital care codes represent the evaluation and management performed at the time of admission.

In 2025, selection is based on:

  • Number and complexity of problems addressed

  • Amount and complexity of data reviewed

  • Risk of complications or morbidity

  • Total time spent reviewing records, evaluating the patient, coordinating care, and documenting

Common clinical situations that drive higher MDM:

  • Acute organ failure

  • Severe infection or sepsis

  • Decompensated chronic disease requiring close monitoring

  • High-risk medications requiring intensive management

  • Multisystem trauma

  • Post-procedural complications

Admission notes must demonstrate why inpatient-level care is necessary.

3. Subsequent Hospital Care (Daily Inpatient Visits)

Subsequent care codes capture the daily management of patients already admitted. Code selection is based on:

  • Changes in clinical status

  • New complications or worsening conditions

  • Review and interpretation of labs, imaging, or consult notes

  • Management of comorbidities

  • Adjustments to treatment plans

  • Coordination with interdisciplinary teams

To support medical necessity, documentation should show:

  • Interval changes or stability

  • Active problems being managed

  • Clinical reasoning behind tests or orders

  • Impact of comorbidities on treatment decisions

Routine “check-ins” without clinical significance do not justify inpatient E/M codes.

4. Discharge Day Management (Final Day of Care)

Discharge codes represent all services performed on the discharge date, including:

  • Final examination

  • Medication reconciliation

  • Review of the hospital course

  • Coordination of follow-up and outpatient care

  • Patient/caregiver instructions

  • Completion of discharge summary and documentation

Time-based selection is allowed and must reflect all discharge-related work performed on that date.

5. Key Documentation Requirements in 2025

For all inpatient E/M services, documentation should reflect:

A. Medically necessary evaluation

Describe the patient’s condition in detail, including severity, risk, and clinical reasoning.

B. Clear medical decision-making

Explain:

  • Differential diagnosis

  • Interpretation of data

  • Risk assessment

  • Treatment rationale

C. Time documentation (when applicable)

Record total time spent on the encounter:

  • Reviewing previous records

  • Examining the patient

  • Coordinating with other clinicians

  • Documenting the visit

  • Ordering tests or therapies

D. Teaching physician requirements

Attending physicians must personally perform or supervise key components and document participation.

E. Social determinants of health (SDOH)

Document SDOH when they increase complexity or risk, such as:

  • Homelessness

  • Limited caregiver support

  • Food insecurity

  • Language or literacy barriers

In 2025, capturing SDOH continues to improve clarity of MDM.

6. Common Coding Scenarios in 2025

A. Emergency Department to Inpatient Admission

If the same provider treats the patient in the ED then admits them the same day:

  • Bill only the inpatient admission code.
    ED visit cannot be billed separately.

B. Observation to Inpatient Conversion

If a patient is converted from observation to inpatient:

  • Bill admission only on the date status is changed.

C. Multiple Specialists

Only the provider assuming responsibility for overall care bills the admission code.
Other specialists bill consultation or subsequent inpatient care codes depending on payer policy.

D. Split/Shared Visits

For shared visits between physicians and APPs:

  • Code selection follows payer rules

  • The clinician performing the substantive portion bills the service

  • Time or MDM can be used to determine substantive involvement

7. Frequent Mistakes and How to Avoid Them

Mistake 1: Under-documenting MDM

Fix: Include severity, instability, and rationale for testing and decisions.

Mistake 2: Using initial care codes when not the admitting provider

Fix: Confirm who assumes overall care.

Mistake 3: Missing time documentation when billing based on time

Fix: Add total minutes and describe medically necessary tasks.

Mistake 4: Over-reliance on templates

Fix: Document patient-specific details, not boilerplate wording.

Mistake 5: Incomplete discharge documentation

Fix: Include instructions, follow-up coordination, and medication review.

8. Best Practices for Accurate Inpatient Coding in 2025

  1. Describe clinical reasoning, not just findings.

  2. Capture all active problems and comorbidities.

  3. Use time-based coding when it best reflects the work performed.

  4. Ensure internal consistency between exam, assessment, and plan.

  5. Coordinate documentation among physicians, APPs, and consultants.

  6. Document SDOH when they impact medical complexity.

  7. Review payer-specific rules for consults and shared visits.

Conclusion

Inpatient CPT codes in 2025 reflect a modern, streamlined documentation framework centered on medical decision-making and total time, allowing clinicians to accurately represent the complexity of hospital care. By understanding how to correctly select and document inpatient admission, subsequent care, and discharge services, providers can ensure compliance, reduce denials, and support proper reimbursement.