Procedure code and Description
99251 Inpatient consultation for a new or established patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are selflimited or minor. Typically, 20 minutes are spent at the bedside and on the patient’s hospital floor or unit.
99252 Inpatient consultation for a new or established patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low severity. Typically, 40 minutes are spent at the bedside and on the patient’s hospital floor or unit.
99253 Inpatient consultation for a new or established patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate severity. Typically, 55 minutes are spent at the bedside and on the patient’s hospital floor or unit.
99254 Inpatient consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 80 minutes are spent at the bedside and on the patient’s hospital floor or unit.
99255 Inpatient consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 110 minutes are spent at the bedside and on the patient’s hospital floor or unit.
Types of Consultations
CPT″ consultation codes are divided into two sections based on place of service:
A. Office or Other Outpatient Consultations:
Office or other outpatient consultations are reported with CPT″ codes 99241-99245 with no distinction between new and established patients. Consultation is appropriate in any outpatient setting including the office, emergency department, home, or domiciliary setting.
B. Inpatient Consultations:
Inpatient consultations are reported with CPT″ codes 99251-99255. The codes are used to report physician or other health care professional consultations provided to hospital inpatients, residents of nursing facilities, or patients in a partial hospital setting.
Initial and Follow-Up Consultation Services
A. Initial Consultation
1. In the hospital and nursing facility setting, the consulting physician or other qualified health care professional shall use the appropriate inpatient consultation CPT″ codes 99251-99255 for the initial consultation service. The initial inpatient consultation may be reported only once per consultant per patient per facility admission.
2. In the office or outpatient setting, the consultant should use the appropriate office or outpatient consultation CPT″ codes 99241-99245 for the initial consultation service. 3. A consulting physician or other qualified health care professional may initiate diagnostic services and treatment at the initial consultation service or may even take over the patient’s care after the initial consultation.
B. Follow-up Services
1. Ongoing management, following the initial consultation service by the consulting physician or other qualified health care professional should not be reported with consultation service codes. These services need to be reported as subsequent visits with the appropriate place of service and level of service.
2. In the hospital setting, following the initial consultation service, the subsequent hospital care CPT″ codes 99231-99233 should be reported for additional follow-up visits. In the nursing facility setting, following the initial consultation service, the subsequent nursing facility care CPT″codes 99307-99310 should be reported for additional follow-up visits.
3. In the outpatient setting, following the initial consultation service, the office or outpatient established patient CPT″ codes 99212-99215 should be reported for additional follow-up visits.
4. If an additional request for an opinion regarding the same or new problem with the same patient is received from the same or another physician or other appropriate source and documented in the medical record, the office or outpatient consultation CPT″ codes 99241- 99245 may be used again • However, if after any consultation service, the consultant then continues to care for the patient for the original condition, such follow-up services should not be reported with consultation service codes.
Medicare Guidelines for consult code 99241 – 99255
• Follow-up visits to a consultation service in the office or other outpatient settings will be reported with the Office or Other Outpatient Established Patient codes 99212-99215.
• Beginning January 1, 2006, in a facility setting a second opinion consultation arranged through the attending physician will be reported by a physician/qualified NPP using an appropriate Initial Inpatient Consultation code when the consultation requirements are met.
• When consultation requirements are not met the Subsequent Hospital Care codes (99231-99233) in the hospital setting and the Subsequent NF Care codes (99307-99310) in the NF setting will be reported.
• In the Office or Other Outpatient setting for a second opinion evaluation, a physician/qualified NPP will use new patient codes (99201-99205) for new patients and established patient codes (99212- 99215) for an established patient, as appropriate.
• Physicians and qualified NPPs must report:
• Initial Inpatient Consultation codes (99251-99255) for an initial consultation and the inpatient hospital setting and the SNF/NF setting; and
• Appropriate Office or Other Outpatient Consultation codes (99241-99245) for and initial consultation in the office/outpatient setting.
• Following the physician’s and qualified NPP’s initial consultation service, the follow-up visits should be reported using the:
• Subsequent Hospital Care codes (99231-99233) for the inpatient hospital setting; and
• Subsequent NF Care codes (99307-99310) in the NF setting; and
• Office or Other Outpatient Established Patient codes (99212-99215) should be reported for the office/outpatient setting.
Billing with Preventive code
Preventive Medicine Services include counseling. When counseling service codes are billed with a Preventive Medicine code on the same date of service by the Same Specialty Physician, Hospital, Ambulatory Surgical Center or Other Health Care Professional, only the Preventive Medicine code is reimbursed.
Consult code replacement CPTs.
Medicare no longer accept consult code. Please find below the crosswalk replacement codes for consult code
CPT Consultative Services Code CPT E/M Codes for Crosswalking Modifier Required
99251 99221 (Inpatient Initial Visit, level 1) Yes, you will need to append Modifier “AI”
99252 99221 (Inpatient Initial Visit, level 1) or 99222 (Inpatient Initial Visit, level 2) Yes, you will need to append Modifier “AI”
99253 99222 (Inpatient Initial Visit, level 1) Yes, you will need to append Modifier “AI”
99254 99222 (Inpatient Initial Visit, level 2) or 99222 (Inpatient Initial Visit, level 3) Yes, you will need to append Modifier “AI”
99255 99223 (Inpatient Initial Visit, level 3) Yes, you will need to append Modifier “AI”
