99253 CPT Code (2022) Description, Guidelines, Reimbursement, Modifiers & Example
99253 CPT code is used to bill inpatient consultation. This is a service provided to a hospital inpatient by a physician whose opinion or another physician or other appropriate source requests advice regarding evaluating and managing a specific problem. This article will help you with proper coding, billing guidelines, modifiers, and reimbursement for 99253 CPT code.
99253 CPT Code Summary
There are five levels under inpatient consultation services for a new or established patient category represented by 99251-99255.
The following is the least you must do to qualify for a hospital consult 99253 CPT code.
It would be best if you had history, physical, and decision-making to qualify in their levels, unlike hospital follow-up visits requiring only 2 out of 3 areas. Remember you will need three out of three for consults:
History (You need all three of these elements)
Four components of the History of present Illness (location, duration, character, onset, associated signs, symptoms, etc. OR the status of a minimum of three chronic medical conditions.
Two reviews of systems. The area from Past Medical, Medications, Allergies, Family, Social history
A comprehensive exam of the affected body area and other symptomatic or related organ systems OR 6 regions (2 bullets each) OR 2+ spaces (12 bullets total). Documenting three vitals is considered a bullet.
Decision Making:
Diagnosis: 2 points
Data: 2 points
Risk: Low
For the Decision-making component, you need the highest two out of three from diagnosis, data, and risk.
An important tip about CPT 99253:
According to CPT guidelines, only one inpatient consultation code from 99251-99255 must be reported by a consultant per admission. Evaluation and Management services after the initial consultation during a single admission should be reported using non-consultation E&M codes. The appropriate follow-up codes for the hospital setting are CPT codes 99231-99233, and the proper follow-up codes for the nursing facility are CPT codes 99307-99310.
99253 CPT Code Description
New or established patient Inpatient consultation for a new or established patient requires these three key elements: An appropriate detailed history, A detailed examination, and medical decision-making of low complexity.
Coordination of care and Counseling with other providers or agencies are provided consistent with the nature of the problem and the patient’s or his family’s demand. Usually, the presenting problems are of moderate intensity or severity. Typically, 55 minutes are spent at the patient’s hospital unit or bedside.
99253 CPT code is the third-highest level of care for hospital consults.
Inpatient consultation service codes describe encounters with patients admitted to the hospital, residing in nursing facilities, or patients in a partial hospital setting where another qualified clinician’s advice or opinion regarding diagnosis and treatment or determination to accept the transfer of care of a patient are rendered at the request of the primary treating provider.
The consultation request must be documented in the patient’s medical record and a confirmed report of the consultation findings to the primary treating physician. The physician consultant can initiate diagnostic or therapeutic services during a consultation or follow-up visit at the same encounter.
Other procedures or services performed with the consultation may be reported separately. Only one inpatient consultation services code should be written per admission, and CPT codes do not differentiate between new or established patients. Services are reported based on meeting all three key components (history, exam, and medical decision-making) within each level of service.
As represented by 99251, the most basic service describes a problem-focused history and exam with straightforward medical decision-making for a minor or self-limiting complaint encompassing approximately 20 minutes at the patient’s bedside or on the unit.
The mid-level services describe problems involving an expanded problem-focused history and exam or a detailed history and exam represented by 99252 and 99253 CPT code, respectively.
Medical decision-making for 99252 is the same (straightforward) as for a level one visit (99251) and is designated as low complexity for the level three service (99253). At these service levels, the encounter can involve time at the patient’s bedside or on the unit of 40 (99252) to 55 (CPT code 99253) minutes involving minimal to low severity concerns.
These codes are used to report consultations in the inpatient setting. All three key elements (history, exam, and medical decision-making) should be equal to or exceeded for the level of E&M service selected. May also use the time to determine the appropriate level of service when counseling and coordination of care are documented as at least half of the time spent face-to-face with the patient.
Consultation code 99253 is not covered by Medicare and some payers. Report new or established inpatient E/M codes for consultation services. Consultation services should not be reported when the care and management of a problem or condition are assumed before the patient’s initial examination. Always write the appropriate initial or subsequent evaluation and management service in these situations.
Do not report inpatient and outpatient consultation codes when both are related to the same inpatient admission.
The provider may report telemedicine services by appending modifier 95 to these procedure codes and using the appropriate place of service. Services at the origination site are registered with HCPCS Level II code Q3014.
99253 CPT Code Reimbursement
If coding is based on time, 55 minutes must be spent face-to-face with the patient.
In addition, the appropriate documentation must be included.
The reimbursement for this CPT code 99253 is approximately $97.20.
When a physician performs the E&M at the request of the patient’s attending physician, the CMS will pay a consultation fee if:
Use of a consultation code criteria met.
The consultation is followed by treatment.
A surgeon requests that another physician participates in postoperative care (provided that the physician did not perform a pre-operative consultation).
99253 CPT Code Billing Guidelines
Cost and Relative value units of the facility services:
The Cost and total RVUs of CPT 99253 are $114.55 and 3.31000, respectively for both National and Global Facility and Non-Facility Services.
Facility codes reflect the volume and ferocity of resources used by the facility to provide care.
The level of E&M service billed must be based on the treatment of a low level of complexity having three key components:
An expanded problem-focused history.
An expanded problem-focused examination.
Straightforward medical decision making performed concerning the medical care required by the reported symptoms and resulting in the patient’s diagnosis.
99253 CPT Code Modifiers
Modifiers provide additional information about the medical procedure, service, or supply involved without changing the meaning of the code.
Modifiers that are applicable with CPT code 99253 are given below:
24, 25, 57, 93, 95, 99, AI, CC, CR, ET, EY, FR, G0, GA, GC, GJ, GK, GQ, GR, GT, GU, GX, GY, GZ, XK, Q5, Q6, QJ, TH.
Modifiers often used in medical coding and billing for 99253 CPT code are 24, 25, 57, 95, and GT.
Modifier 25 With Example
When another minor or major procedure is performed, a Separate identifiable Evaluation and Management service is carried out on the Same Day by the Same Physician or Other Qualified Health Care Professional.
Use modifier 25 on an E/M service performed during the same session as a preventive care visit when significant, separately identifiable E/M service is rendered in addition to the preventive care.
Use modifier 25 when the Evaluation and management service is Distinct, significantly identifiable, and separately documented as another service different from the E&M service.
Example:
ENT Inpatient consultation for shortness of breath, Hoarseness, and difficulty swallowing. A flex laryngoscopy was performed during the consult and found a laryngeal mass. In this case, modifier 25 would be appended to 99253.
Modifier 24 With Example
During a global fee period (postoperative) of an effective procedure, Unrelated Evaluation and Management service is carried out on the Same Day by the Same Physician or Other Qualified Health Care Professional.
Modifier 24 is appended with the E&M code when a patient is in the global fee period of a major or minor procedure performed within the global fee period. Still, They returned for a different condition or procedure with another Diagnosis code.
Example:
A patient came in for postoperative consultation. He had S/P Discectomy 12 weeks ago. The patient C/O severe headache with visual changes, proceeded by an aura during the exam. In this case, append modifier 24 to the E&M consultation code.
Modifier 95 and GT
Both modifiers have almost the exact description and use. These are Synchronous Telemedicine Services provided through a Real-Time Interactive video or audio Telephonic, or telecommunication approach. Only the difference is Modifier 95 is used for Commercial insurance, and GT is used for Medicare.
Telemedicine service is a real-time interaction of a physician with the patient located far away from the physician’s office. Therefore, the information exchanged between the patient and physician or other qualified health care professionals during the telephonic communication service must be sufficient to meet the key components and requirements of the service when provided via direct face-to-face interaction.
Modifier 57 With Example
57- “Decision for surgery.” An E&M service resulted in the decision to perform the significant/major surgery identified using a 57-modifier to the appropriate level of E/M service.
Use Modifier 57 to indicate an Evaluation and Management (E/M) service when the initial decision to perform surgery is the day before major surgery (90 days global) or the day of major surgery.
Example:
A patient came for low complexity inpatient consultation for stomachache and abdominal tenderness; an endoscopy was performed and revealed 4cm of benign neoplasm of the small intestine. The Doctor performed a tissue biopsy and decided to remove the neoplasm the next day. So, in this case, modifier 57 should be appended to CPT 99253 on the day the biopsy was done and the Doctor decided to do major surgery.
99253 CPT Code Examples
The following are examples when the 99253 CPT code may be billed.
Example 1
Initial hospital consultation for 50-year-old female with incapacitating knee pain due to generalized rheumatoid arthritis. (Orthopeadic Surgery)
Example 2
Initial hospital consultation for a 60-year-old male with avascular necrosis of the left femoral heel with increasing pain. (Orthopaedic Surgery)
Example 3
Initial hospital consultation for a 45-year-old female with compound mandibular fracture and concurrent head, abdominal, and/or orthopaedic injuries. (Oral & Maxillofacial)
Example 4
Initial hospital consultation for a 22-year-old female, paraplegic, to evaluation wrist and hand pain. (Orthopaedic Surgery)
Example 5
Initial hospital consultation for a 40-year-old male with 10-day history of incapacitating unilateral sciatica, unable to walk now, not improved by bed rest. (Neurosurgery)
Example 6
Initial hospital consultation, requested by pediatrician, for treatment recommendations for a patient admitted with persistent inability to walk following soft tissue injury to ankle. (Physiatry)
Example 7
Initial hospital consultation for a 27-year-old previously healthy male who vomited during IV sedation and may have aspirated gastric contents. (Anesthesiology)
Example 8
Initial hospital consultation for a 33-year-old female, post-abdominal surgery, who now has a fever. (Internal Medicine)
Example 9
Initial inpatient consultation for a 57-year-old male, post lower endoscopy, for evaluation of abdominal pain and fever. (General Surgery)
Example 10
Initial inpatient consultation for rehabilitation of a 73-year-old female one week after management of a hip fracture. (Physical Medicine & Rehabilitation)
Example 11
Initial inpatient consultation for diagnosis/management of fever following abdominal surgery. (Internal Medicine)
Example 12
Initial inpatient consultation for a 35-year-old female with a fever and pulmonary infiltrate following cesarean section. (Pulmonary Medicine)
Example 13
Initial inpatient consultation for a 42-year-old non-diabetic patient, postoperative cholecystectomy, now with an acute urinary tract infection. (Nephrology)
Example 14
Initial inpatient consultation for 53-year-old female with moderate uncomplicated pancreatitis. (Gastroenterology)
Example 15
Initial inpatient consultation for 45-year-old patient with chronic neck pain with radicular pain of the left arm. (Orthopaedic Surgery)
Example 16
Initial inpatient consultation for 8-year-old patient with new onset of seizures who has a normal examination and previous history. (Neurology)
