99254 CPT Code

99254 CPT Code (2022) Description, Guidelines, Reimbursement, Modifiers & Examples

The 99254 CPT code is a consultation code. Inpatient consultation is a service provided to a hospital inpatient by a physician whose opinion or another physician’s opinion or other appropriate source requests advice regarding evaluating and managing a specific problem.

Be aware that CPT 99254 was revised on 01-01-2023. This article covers the previous code description.

Summary

There are five levels under inpatient consultation services for a new or established patient category represented by 99251-99255. 99254 CPT code is the level of moderate complexity.

It would be best to have comprehensive history, physical examination, and decision-making to qualify at their levels, unlike hospital follow-up visits requiring only two out of three areas. Remember, for consults; you need three out of three.

The example qualifies as a Comprehensive history which requires a chief complaint, a comprehensive History consisting of four HPI components(or the status of three chronic or inactive problems), a complete Review of the system(which requires at least ten systems)and a complete Past family and social history(which in this case requires at least one element from each Past family and social history category).

The requirements for the History of the present Illness are met by commenting on the status of three chronic or inactive problems (hypertension, ischemic cardiomyopathy, and diabetes). The Past family and social history elements used are self-explanatory.

Note that at least a component from each category of PFSH is present. Fulfilled The Review of the systems requirements by commenting on pertinent findings and using the accepted ROS shorthand of “All others negative.” 

Decision-Making points:

Diagnosis: 3 points

Data: 3 points

Risk: moderate

For the Decision-making component, you need the highest two out of three from diagnosis, data, and risk. 

An important tip about CPT 99254:

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.

Code Description

New or established patient Inpatient consultation requires these three key components: A comprehensive history, A comprehensive examination, and medical decision-making of moderate complexity. 

The official description of CPT 99254 is: 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 physicians, other qualified health care professionals, 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.”

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, 80 minutes are spent at the patient’s hospital unit or bedside.

The 99254 CPT code is the fourth-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. 

Must document the consultation request 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.

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. 

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 (99253) minutes involving minimal to low severity concerns.

The moderate-level services 99254 CPT code describe problems involving comprehensive history, A comprehensive examination, and medical decision-making.

Other procedures or services performed with the consultation may be reported separately. Must write only one inpatient consultation services code 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. 

Consultation code CPT 99254 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.

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.

Note: Do not report inpatient and outpatient consultation codes when both are related to the same inpatient admission.

cpt 99254

Reimbursement

If coding is based on time, you must spend 55 minutes face-to-face with the patient. Must include the appropriate documentation.

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).

Consult code replacement CPTs.

Medicare no longer accepts consultation codes. Please find below replacement codes for the consult code.

CPT E&M Codes for Crosswalking Modifier:

99251 to 99221 (Inpatient level 1 initial visit), you must append Modifier AI.

99252 to 99221 (Inpatient level 1 initial visit) or 99222 (Inpatient level 2 visit) append Modifier AI.

99253 to 99222 (Inpatient level 1 visit) append Modifier AI.

99254 CPT code to 99222 (Inpatient level 2 stop) or 99222 (Inpatient level 3), you must append Modifier AI.

99255 to 99223 (Inpatient level 3 visit). You must append Modifier AI.

Billing Guidelines

Cost and Relative value units of the facility services:

The Cost and total RVUs of CPT 99254 are $165.07 and 4.77000, respectively for both National and Global Facility and Non-Facility Services.

Facility codes reflect the volume and ferocity of resources the facility uses to provide care.

The level of E&M service 99254 CPT code billed must be based on the treatment of a moderate level of complexity having three key components:

  • Comprehensive History
  • Comprehensive Exam
  • Moderate complexity of medical decision-making

Billing Examples

The examples below are when cases when the 99254 CPT code may be billed.

Example 1

Initial in-patient consultation for a 15-year-old patient with painless swelling of the proximal humerus with lytic lesion by X-ray. (Orthopaedic Surgery)

Example 2

Initial hospital consultation for evaluation of a 29-year-old female with a diffusely positive medical review of systems and history of multiple surgeries. (Psychiatry)

Example 3

Initial hospital consultation for a 70-year-old diabetic female with gangrene of the foot. (Orthopaedic Surgery)

Example 4

Initial inpatient consultation for a 47-year-old female with progressive pulmonary infiltrate, hypoxemia, and diminished urine output. (Anaesthesiology)

Example 5

Initial hospital consultation for a 13-month-old with spasmodic cough, respiratory distress, and fever. (Allergy & Immunology)

Example 6

Initial consultation for a patient with failed total hip replacement with loosening and pain upon walking. (Orthopaedic Surgery)

Example 7

Initial hospital consultation for a 62-year-old female with metastatic breast cancer to the femoral neck and thoracic vertebra. (Orthopaedic Surgery)

Example 8

Initial hospital consultation for a 39-year-old female with nephrolithiasis requiring extensive opioid analgesics, whose vital signs are now elevated; she initially denied any drug use but today gives a history of multiple substance abuse, including opioids and prior treatment for a personality disorder. (Psychiatry)

Example 9

Initial hospital consultation for a 70-year-old female without previous psychiatric history who is now experiencing nocturnal confusion and visual hallucinations following hip replacement surgery. (Psychiatry)

Example 10

Initial inpatient consultation to evaluate a 63-year-old in the ICU with diabetes and chronic renal failure who develops acute respiratory distress syndrome 36 hours after a mitral valve replacement. (Anaesthesiology)

Example 11

Initial inpatient consultation for a 66-year-old female with enlarged supraclavicular lymph nodes, found on biopsy to be malignant. (Haematology/Oncology)

Example 12

Initial inpatient consultation for a 43-year-old female for evaluation of sudden, painful visual loss, optic neuritis, and episodic paresthesia. (Ophthalmology)

Example 13

Initial inpatient consultation for evaluation of a 71-year-old male with hyponatremia (serum sodium 114) admitted to the hospital with pneumonia. (Nephrology)

Example 14

Initial inpatient consultation for a 72-year-old male with emergency admission for possible bowel obstruction. (Internal Medicine/General Surgery)

Example 15

Initial inpatient consultation for a 35-year-old female with fever, swollen joints, and a rash of one-week duration. (Rheumatology)

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