99254 CPT Code (2022) Description, Guidelines, Reimbursement, Modifiers & Examples
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.
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 in 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 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.”
Diagnosis: 3 points
Data: 3 points
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.
99254 CPT 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.
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.
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.
99254 CPT Code 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 will need to 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 will need to append Modifier AI.
99255 to 99223 (Inpatient level 3 visit) You must append Modifier AI.
99254 CPT Code 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 used by the facility 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
99254 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 99254 are given below:
24, 25, 57, 93, 95, 99, AI, CC, CR, ET, EY, FR, FS, G0, GA, GC, GJ, GK, GQ, GR, GT, GU, GX, GY, GZ, XK, Q5, Q6, QJ, TH.
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.
An established patient came in for postoperative inpatient consultation for low back pain. He had Staus Post Discectomy (herniated lumbar disc removed) 12 weeks ago. Now, the patient Complains of severe chest pain that is parasternal and shooting in nature with palpitations proceeded by an aura during the exam.
In this case, append modifier 24 to the E&M consultation code. Because the patient reports another problem rather than the lower back, which he had surgery on and has a 90-day global period.
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 physician interaction 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.
A patient came for inpatient consultation for upper abdominal tenderness; an endoscopy was performed and revealed 3cm of benign neoplasm of the duodenum. The Doctor performed a tissue biopsy and decided to remove the neoplasm the very next day. In this case, modifier 57 should be appended to the E&M code on the day when the biopsy was done, and the Doctor decided to do major surgery.
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.
Add 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.
A patient referred by a physician visits the pulmonologist for an appointment complaining of occasional chest discomfort during exercise. In addition, the patient had a history of pulmonary hypertension and high cholesterol.
After the physician finishes the checkup, it is determined that the patient needs a cardiovascular stress test performed that day by the same physician. So, in this case, append modifier 25 to the E&M code.
99254 CPT Code Examples
The following examples are when the 99254 CPT code may be billed.
Initial in patient consultation for a 15-year-old patient with painless swelling of proximal humerus with lytic lesion by X-ray. (Orthopaedic Surgery)
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)
Initial hospital consultation for a 70-year-old diabetic female with gangrene of the foot. (Orthopaedic Surgery)
Initial inpatient consultation for a 47-year-old female with progressive pulmonary infiltrate, hypoxemia, and diminished urine output. (Anaesthesiology)
Initial hospital consultation for a 13-month-old with spasmodic cough, respiratory distress, and fever. (Allergy & Immunology)
Initial consultation for a patient with failed total hip replacement with loosening and pain upon walking. (Orthopaedic Surgery)
Initial hospital consultation for a 62-year-old female with metastatic breast cancer to the femoral neck and thoracic vertebra. (Orthopaedic Surgery)
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 history of multiple substance abuse, including opioids and prior treatment for a personality disorder. (Psychiatry)
99254 CPT Code 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)
99254 CPT Code Example 10
Initial inpatient consultation for evaluation of a 63-year-old in the ICU with diabetes and chronic renal failure who develops acute respiratory distress syndrome 36 hours after a mitral value replacement. (Anaesthesiology)
99254 CPT Code Example 11
Initial inpatient consultation for a 66-year-old female with enlarged supraclavicular lymph nodes, found on biopsy to be malignant. (Haematology/Oncology)
99254 CPT Code Example 12
Initial inpatient consultation for a 43-year-old female for evaluation of sudden painful visual loss, optic neuritis, and episodic paresthesia. (Ophthalmology)
99254 CPT Code Example 13
Initial inpatient consultation for evaluation of a 71-year-old male with hyponatremia (serum sodium 114) who was admitted to the hospital with pneumonia. (Nephrology)
99254 CPT Code Example 14
Initial inpatient consultation for a 72-year-old male with emergency admission for possible bowel obstruction. (Internal Medicine/General Surgery)
99254 CPT Code Example 15
Initial inpatient consultation for a 35-year-old female with fever, swollen joints, and rash of one-week duration. (Rheumatology)