CPT Code 99221 – CPT Code 99255 (2021)

Definitions Of CPT Codes

CPT 99221: Under New or Established Patient Initial Hospital Inpatient Care Services.

CPT 99231: Under Subsequent Hospital Care Services.

CPT 99232: Under Subsequent Hospital Care Services.

CPT 99233: Under Subsequent Hospital Care Services.

CPT 99241: Under New or Established Patient Office or Other Outpatient Consultation Services

CPT 99251: Under New or Established Patient Initial Inpatient Consultation Services.

CPT 99252: Under New or Established Patient Initial Inpatient Consultation Services.

CPT 99255: Under New or Established Patient Initial Inpatient Consultation Services.

CPT 99221 & CPT 99233 VS CPT 99241 & CPT 99255

Can we bill CPT 99221 as a replacement code for Hospital Consultations that do not met “a detailed or comprehensive history” and “a detailed or comprehensive examination?

No you cannot report CPT 99221 since physicians must meet all the requirements of the initial hospital care codes, including “a detailed or comprehensive history” and “a detailed or comprehensive examination” to report CPT code 99221, which are greater than the requirements for consultation codes CPT 99251 and CPT 99252.

In situations where the minimum key component work and/or medical necessity requirements for initial hospital care services are not met, subsequent hospital care CPT codes (CPT 99231 and CPT 99232) could potentially be reported for an E/M service that could be described by CPT consultation code CPT 99251 or CPT 99252.

Subsequent hospital care codes CPT 99231 and CPT 99232, respectively, require “a problem focused interval history” and “an expanded problem focused interval history.”

An E/M service that could be described by CPT consultation code CPT 99251 or CPT 99252 could potentially meet the component work and medical necessity requirements to report CPT 99231 or CPT 99232.

Physicians may report a subsequent hospital care CPT code for services that were reported as CPT consultation codes (CPT 99241 – CPT 99255) prior to January 1, 2010, where the medical record appropriately demonstrates that the work and medical necessity requirements are met for reporting a subsequent hospital care code (under the level selected), even though the reported code is for the provider’s first E/M service to the inpatient during the hospital stay.

Subsequent hospital care CPT codes 99231 and CPT 99232, respectively, require “a problem focused interval history” and “an expanded problem focused interval history.”

An E/M service that could be described by CPT consultation code CPT 99251 or CPT 99252 could potentially meet the component work and medical necessity requirements to report CPT 99231 or CPT 99232.

Physicians may report a subsequent hospital care CPT code for services that were reported as CPT consultation codes (CPT 99241 – CPT 99255) prior to January 1, 2010, where the medical record appropriately demonstrates that the work and medical necessity requirements are met for reporting a subsequent hospital care code (under the level selected), even though the reported code is for the provider’s first E/M service to the inpatient during the hospital stay.

Sidenote

Medicare contractors have been advised to expect changes to physician billing practices accordingly.

Contractors will not find fault with providers who report subsequent hospital care codes (99231 and 99232) in cases where the medical record appropriately demonstrates that the work and medical necessity requirements are met for reporting a subsequent hospital care code (under the level selected),even though the reported code is for the provider’s first E/M service to the inpatient during the hospital stay.