This article will define CPT Code 99255, explain the medical necessity to report CPT 99255, the guidelines and clinical examples of CPT 99255.
CPT Code 99255 Description
CPT Code 99255 is defined by the CPT manual as follows (the text in Italic is the official definition of CPT 99255):
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 high 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 110 minutes at the bedside and on the patient’s hospital floor or unit.
The CPT codes for visits are split into two sections according to the place of performance:
1. Outpatient visits and / or other outpatient consultations: Outpatient visits or other external consultations are reported with CPT codes 99241 – 99245 without a contrast between new patients and already established patients. Consultation is needed in any outpatient setting, including the office, emergency room, or home setting.
2. Hospital visits: Hospital visits are reported under CPT codes 99251 – 99255. Codes are used to report medical or other health care professional advice given to inpatient, nursing facility residents, or patients in a partial hospital setting.
CPT Code 99255 Examples
Initial inpatient consultation for a 76-year-old female with massive, life-treatening gastrointestinal hemorrhage and chest pain. (Gastroenterology)
Initial inpatient consultation for a 75-year-old female, admitted to intensive care with acute respiratory distress syndrome, who is hypersensitive, and has a moderate metabolic acidosis, and a rising serum creatinine. (Nephrology)
Initial hospital consultation for patient with a history of complicated low back pain and neck problems with previous multiple failed back surgeries. (Orthopaedic surgery/Neurosurgery)
Initial hospital consultation for a 66-year-old female, two days post-abdominal aneurysm repair, with oliguria and hypertension of one-day duration. (Nephrology/Internal Medicine)
Initial hospital consultation for a patient with shotgun wound to face with massive facial trauma and airway obstruction. (Oral & Maxillofacial Surgery)
Initial hospital consultation for patient with server pancreatitis complicated by respiratory insufficiency, acute renal failure, and abscess formation. (General Surgery/Colon & Rectal Surgery)
Initial hospital consultation for a 35—year-old multiple-trauma male patient with complex pelvic fractures to evaluate and formulate management plan. (Orthopedic Surgery)
Initial inpatient consultation for adolescent patient with fractured femur and pelvis who pulled out IVs and disconnected traction in attempt to elope from hospital. (Psychiatry)
Initial hospital consultation for a 16-year-old primigravida at 32-weeks gestation requested by a family practitioner for evaluation of severe hypertension, thrombocytopenia, and headache. (Obstetrics & Gynecology)
Initial hospital consultation for 58-year-old insulin-dependent diabetic with multiple antibiotic allergies, now with multiple fascial plane plane abscesses and airway obstruction. (Oral & Maxillofacial Surgery)
Initial inpatient consultation for a 55-year-old male with known cirrhosis and ascites, now with jaundice, encephalopathy, and massive hematemesis. (Gastroenterology)
Initial hospital consultation for a 25-year-old male, seen in emergency room with server, closed head injury. (Neurosurgery)
Initial hospital consultation for a 2-day male with single ventricle physiology and subaortic obstruction, Family counseling following evaluation for multiple, staged surgical procedures. (Thoracic Surgery)
Initial hospital consultation for a 45-year-old male admitted with subarachnoid hemorrhage and intracranial aneurysm on angiogram. (Neurosurgery)
Initial inpatient consultation for myxedematous patient who is hypoventilating and obtunded. (Endocrinology)
Initial hospital consultation for a 45-year-old patient with widely metastatic lung carcinoma, intractable back pain, and a history that includes substance dependence, NSAID allergy, and two prior laminectomies with fusion for low back pain. (Pain Medicine)
Initial hospital consultation for evaluation of treatment options in a 50-year-old patient with cirrhosis, known peptic ulcer disease, hypotension, encephalopathy, and massive acute upper gastrointestinal bleeding that cannot be localized by endoscopy. (Interventional Radiology)
Initial inpatient consultation in the ICU for a 70-year-old male who experienced a cardiac arrest during surgery and was resuscitated. (Cardiology)
Initial inpatient consultation for a patient with severe pancreatitis complicated by respiratory insufficiency, acute renal failure, and abscess formation. (Gastroenterology)
Initial inpatient consultation for a 70-year-old cirrhotic male admitted with ascites, jaundice, encephalopathy, and massive hematemesis. (Gastroenterology)
Initial inpatient consultation in the ICU for a 51-year-old patient who is an a ventilator and has a fever two weeks after a renal transplantation. (Infectious Disease)
Initial inpatient consultation for evaluation and formulation of plan for management of multiple-trauma patient with complex pelvic fracture, 35-year-old male, (General Surgery/Orthopaedic Surgery)
Initial inpatient consultation for a 50-year-old male with a history of previous myocardial infarction, now with acute pulmonary edema and hypotension. (Cardiology)
Initial inpatient consultation for 45-year-old male with recent, acute subarachnoid hemorrhage, hesitant speech, mildly confused, drowsy, High risk group for HIV+ status. (Neurosurgery)
Initial inpatient consultation for 36-year-old female referred by her internist to evaluate a patient being followed for abdominal pain and fever, The patient has developed diffuse abdominal pain, guarding, rigidity, and increased fever. (Obstetrics & Gynecology)