cpt 99254

CPT Code 99254 – Description & Clinical Examples

This article will define CPT Code 99254, explain the medical necessity to report CPT 99254, the guidelines and clinical examples of CPT 99254.

CPT Code 99254 Description

CPT Code 99254 is defined by the CPT manual as follows (the text in Italic is the official definition of CPT 99254):

Inpatient consultation for a new or established patient, which requires these 3 key components: 

  • Component 1: A comprehensive history
  • Component 2: A comprehensive examination
  • Component 3: Medical decision making of moderate complexity

Counselling 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 problem(s) are of moderate to severity. Physicians typically spend 80 minutes at the bedside and on the patient’s hospital floor or unit.

CPT Code 99254 Examples

Example 1

Initial in patient consultation for a 15-year-old patient with painless swelling of 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 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 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)

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) who was 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 rash of one-week duration. (Rheumatology)

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