How To Use CPT Code 99252

CPT 99252 is a code used for inpatient or observation consultations involving straightforward medical decision making or at least 35 minutes of total time spent on the encounter. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, similar codes, and examples of CPT 99252.

1. What is CPT 99252?

CPT 99252 is a code used to describe an inpatient or observation consultation service provided by a healthcare professional for a new or established patient. The consultation involves evaluation and management (E/M) services, which require a medically appropriate history and/or examination and straightforward medical decision making. The code is applicable when the provider spends at least 35 minutes of total time on the encounter or when the level of medical decision making involved is straightforward.

2. 99252 CPT code description

The official description of CPT code 99252 is: “Inpatient or observation consultation for a new or established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 35 minutes must be met or exceeded.”

3. Procedure

The 99252 CPT code procedure involves the following steps:

  1. Reviewing tests and preparing for the patient visit
  2. Performing a medically appropriate history and/or examination
  3. Evaluating the patient’s condition and determining the level of medical decision making required
  4. Counseling and educating the patient or caregiver
  5. Ordering tests and communicating with other healthcare providers
  6. Documenting the encounter
  7. Interpreting and communicating results
  8. Coordinating care with other healthcare professionals or agencies

4. Qualifying circumstances

Patients eligible to receive CPT code 99252 services include those who are in an inpatient or observation setting and require a consultation involving evaluation and management services. The consultation must involve a medically appropriate history and/or examination and straightforward medical decision making. The provider must spend at least 35 minutes of total time on the encounter or the level of medical decision making involved must be straightforward.

5. When to use CPT code 99252

It is appropriate to bill the 99252 CPT code when a healthcare professional provides an inpatient or observation consultation for a new or established patient, and the consultation involves evaluation and management services that require a medically appropriate history and/or examination and straightforward medical decision making. The code should be used when the provider spends at least 35 minutes of total time on the encounter or when the level of medical decision making involved is straightforward.

6. Documentation requirements

To support a claim for CPT 99252, the following information must be documented:

  • Request for consultation from an appropriate source
  • Medically appropriate history and/or examination performed
  • Level of medical decision making involved
  • Total time spent on the encounter
  • Services provided, including counseling, education, and care coordination
  • Communication of opinion and information on services rendered to the requesting source

7. Billing guidelines

When billing for CPT code 99252, it is essential to follow these guidelines:

  • Confirm payer policy regarding the use and coverage of this code
  • Select the E/M service level based on the total time or medical decision making level stated in the code descriptor
  • Ensure that all services performed are documented appropriately in the medical record

8. Historical information

CPT 99252 was added to the Current Procedural Terminology system on January 1, 1992. There have been several updates to the code since its addition, with the most recent change occurring on January 1, 2023.

9. Similar codes to CPT 99252

Five similar codes to CPT 99252 and how they differentiate are:

  • CPT 99251: Involves a lower level of medical decision making or less total time spent on the encounter
  • CPT 99253: Involves a higher level of medical decision making or more total time spent on the encounter
  • CPT 99254: Involves an even higher level of medical decision making or significantly more total time spent on the encounter
  • CPT 99255: Involves the highest level of medical decision making or the most total time spent on the encounter
  • CPT 99241: Used for outpatient consultations instead of inpatient or observation settings

10. Examples

Here are 10 detailed examples of CPT code 99252 procedures:

  1. A patient with a history of hypertension is admitted to the hospital for observation due to chest pain. The attending physician requests a consultation from a cardiologist, who spends 40 minutes evaluating the patient and determining the appropriate course of action.
  2. An elderly patient with a history of diabetes is admitted to the hospital for observation due to a non-healing foot ulcer. The attending physician requests a consultation from an endocrinologist, who spends 35 minutes evaluating the patient and determining the appropriate course of action.
  3. A patient with a history of chronic obstructive pulmonary disease (COPD) is admitted to the hospital for observation due to shortness of breath. The attending physician requests a consultation from a pulmonologist, who spends 45 minutes evaluating the patient and determining the appropriate course of action.
  4. A patient with a history of congestive heart failure is admitted to the hospital for observation due to worsening edema. The attending physician requests a consultation from a cardiologist, who spends 50 minutes evaluating the patient and determining the appropriate course of action.
  5. A patient with a history of chronic kidney disease is admitted to the hospital for observation due to elevated creatinine levels. The attending physician requests a consultation from a nephrologist, who spends 40 minutes evaluating the patient and determining the appropriate course of action.
  6. A patient with a history of liver cirrhosis is admitted to the hospital for observation due to jaundice. The attending physician requests a consultation from a hepatologist, who spends 35 minutes evaluating the patient and determining the appropriate course of action.
  7. A patient with a history of rheumatoid arthritis is admitted to the hospital for observation due to a flare-up of joint pain. The attending physician requests a consultation from a rheumatologist, who spends 45 minutes evaluating the patient and determining the appropriate course of action.
  8. A patient with a history of epilepsy is admitted to the hospital for observation due to a recent seizure. The attending physician requests a consultation from a neurologist, who spends 50 minutes evaluating the patient and determining the appropriate course of action.
  9. A patient with a history of inflammatory bowel disease is admitted to the hospital for observation due to abdominal pain. The attending physician requests a consultation from a gastroenterologist, who spends 40 minutes evaluating the patient and determining the appropriate course of action.
  10. A patient with a history of multiple sclerosis is admitted to the hospital for observation due to worsening neurological symptoms. The attending physician requests a consultation from a neurologist, who spends 35 minutes evaluating the patient and determining the appropriate course of action.

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