How To Use CPT Code 99255

CPT 99255 is an inpatient or observation consultation code for a new or established patient requiring a medically appropriate history and/or examination and high level of medical decision making. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, similar codes, and examples of CPT 99255.

1. What is CPT 99255?

CPT 99255 is a code used to describe an inpatient or observation consultation service provided by a healthcare professional for a new or established patient. This code is applicable when the consultation involves a medically appropriate history and/or examination and a high level of medical decision making. The code is used by medical coders and billers to accurately report and bill for the services provided during the consultation.

2. 99255 CPT code description

The official description of CPT code 99255 is: “Inpatient or observation consultation for a new or established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 80 minutes must be met or exceeded.”

3. Procedure

The 99255 CPT code procedure involves the following steps:

1. Receiving a consultation request from an appropriate source (e.g., qualified healthcare professional, social worker, insurance company).
2. Reviewing the patient’s medical history and any relevant test results.
3. Performing a medically appropriate history and/or examination of the patient.
4. Evaluating the patient’s condition and determining the level of medical decision making required.
5. Providing counseling and education to the patient or caregiver, if necessary.
6. Ordering any necessary tests or treatments.
7. Communicating with other healthcare providers involved in the patient’s care.
8. Documenting the encounter and the services provided.
9. Communicating the consultation findings and recommendations to the requesting source.

4. Qualifying circumstances

Patients eligible to receive CPT code 99255 services include those who are in an inpatient or observation setting and require a consultation involving a medically appropriate history and/or examination and a high level of medical decision making. The consultation must be requested by an appropriate source, and the healthcare professional providing the consultation must communicate their findings and recommendations to the requesting source.

5. When to use CPT code 99255

CPT code 99255 should be used when a healthcare professional provides an inpatient or observation consultation for a new or established patient that involves a medically appropriate history and/or examination and a high level of medical decision making. The total time spent on the date of the encounter must be at least 80 minutes, including both face-to-face and non-face-to-face activities related to the encounter.

6. Documentation requirements

To support a claim for CPT 99255, the following information should be documented:

• The consultation request from an appropriate source.
• A detailed account of the patient’s medical history and any relevant test results.
• A description of the medically appropriate history and/or examination performed.
• An assessment of the patient’s condition and the level of medical decision making required.
• Any counseling or education provided to the patient or caregiver.
• Orders for tests or treatments, if applicable.
• Communication with other healthcare providers involved in the patient’s care.
• A summary of the consultation findings and recommendations.
• Confirmation that the findings and recommendations were communicated to the requesting source.
• The total time spent on the date of the encounter, including both face-to-face and non-face-to-face activities.

7. Billing guidelines

When billing for CPT code 99255, it is important to follow these guidelines:

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

8. Historical information

CPT 99255 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 99255

Five similar codes to CPT 99255 include:

• CPT 99251: Inpatient or observation consultation with a lower level of medical decision making or shorter total time spent on the encounter.
• CPT 99252: Inpatient or observation consultation with a moderate level of medical decision making or longer total time spent on the encounter compared to CPT 99251.
• CPT 99253: Inpatient or observation consultation with a higher level of medical decision making or longer total time spent on the encounter compared to CPT 99252.
• CPT 99254: Inpatient or observation consultation with a higher level of medical decision making or longer total time spent on the encounter compared to CPT 99253.
• CPT 99418: Prolonged services code for consultations lasting 95 minutes or longer.

10. Examples

Here are 10 detailed examples of CPT code 99255 procedures:

1. A patient with multiple organ failure requiring a comprehensive evaluation and management by a specialist, including a high level of medical decision making and at least 80 minutes spent on the encounter.
2. An inpatient consultation for a patient with a complex medical history, requiring a detailed examination, high level of medical decision making, and coordination of care with multiple healthcare providers.
3. A patient in the observation unit with a complicated infection requiring a thorough evaluation, high level of medical decision making, and extensive counseling and education for the patient and their family.
4. An inpatient consultation for a patient with a rare genetic disorder, requiring a comprehensive history and examination, high level of medical decision making, and coordination of care with a multidisciplinary team.
5. A patient with a severe traumatic brain injury requiring an in-depth evaluation, high level of medical decision making, and coordination of care with neurosurgeons, neurologists, and rehabilitation specialists.
6. An inpatient consultation for a patient with advanced cancer, requiring a detailed examination, high level of medical decision making, and extensive counseling and education on treatment options and prognosis.
7. A patient in the observation unit with a complicated postoperative course, requiring a thorough evaluation, high level of medical decision making, and coordination of care with the surgical team and other specialists.
8. An inpatient consultation for a patient with a complex psychiatric condition, requiring a comprehensive history and examination, high level of medical decision making, and coordination of care with mental health professionals.
9. A patient with a life-threatening illness requiring an in-depth evaluation, high level of medical decision making, and extensive counseling and education on end-of-life care and advance directives.
10. An inpatient consultation for a patient with a complicated pregnancy, requiring a detailed examination, high level of medical decision making, and coordination of care with obstetricians, perinatologists, and neonatologists.