If you've found this post, you're looking for information on how to bill CPT® 99254, the inpatient hospital consult E&M code. I'm going to give you a free coding clinic on how to do just that. I am a hospitalist who has been in private practice for almost a decade. I have spent hundreds of hours studying the ins and outs of evaluation and management coding. Just remember one thing, Medicare no longer recognizes any of the inpatient consultation codes. You are instead directed to use the initial hospital encounter codes 99221-99223 for any Medicare beneficiary. Some insurance still pay for consult codes and that's what you're here to learn about.
If you haven't seen my other medical billing and coding lectures, you're missing out on the opportunity to submit the correct CPT® code every time and accurately get paid for the work you are providing your patients. You're also missing out on tens of thousands of dollars of revenue that could be yours simply by understanding how E/M works.
When you get a chance, make sure you check out my other free lectures on the inpatient hospital follow up CPT® codes 99231, 99232 and 99233. You'll also find information on my initial hospital admission codes 99221, 99222 and 99223 which, as you'll find out require the exact same documentation as the observation codes 99218, 99219 and 99220 respectively. Interestingly enough, these codes also require the same documentation as admit discharge same day codes 99234, 99235 and 99236, respectively.
Now it's time to learn about how to bill CPT® 99254, the mid-high level hospital consult code. There are five hospital consult codes 99251, 99252, 99253, 99254 and 99255. I have never billed a 99252 or 99251. I rarely bill this code, CPT® 99254, because most patients who meet the criteria for a CPT® 99254 will meet the criteria for the highest level hospital consult CPT® 99255 if you know what you need to document of the work you are already providing.
If you want to make things really simple, simply click on any of the above links for the documentation requirements of CPT® 99222, CPT® 99219 or CPT® 99235. The evaluation and management requirements necessary for these three codes are exactly the same as those of the CPT® 99254 consult code. Exactly the same. 99254=99222=99219=99235. See how easy this is?
As usual, read the following:
I am not a licensed coding compliance officer. I am a hospitalist physician with years of experience studying this stuff. Read at your own risk. My interpretations here are based on my review of the 1995 and 1997 guidelines and the CMS E/M guide along with the Marshfield Clinic point system for medical decision making.
The Marshfield Clinic point system is voluntary for Medicare carriers but has become the standard in most parts of the country. However, you should check with your own Medicare carrier in your state to verify whether or not they use a different standard than that for which I have presented here on my free educational discussion.
Some carriers in some states utilize the Trailblazer EM tool. There are a few key differences with Trailblazer vs Marshfield in how Medicare carriers are to interpret evaluation and management documentation. Here is a summary of those key differences. Here is the actual link to the Trailblazer E/M Audit reference pdf. If your carrier uses Trailblazer, this discussion may help you, but these additional resources should be reviewed as well for clarity.
How does the AMA define a CPT® 99254
?
?Inpatient consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling 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.
The rules are highly complicated. Getting the right code every time is not. I have developed a bedside quick reference E/M pocket card (see below) that I carry around with me at all times to help me understand all the CMS guidelines.
The following is the exact bare minimum you must do in order to qualify for a hospital consult CPT® code 99254. As I stated above, the requirements are exactly the same as CPT® codes 99222, 99219 and 99235. Exactly the same. So here it is: the 99254. You need history, physical AND decision making to qualify in their respective levels, unlike hospital follow up visits that need just 2 out of 3 areas. Remember, for consults, you need 3 out of 3:
History (You need all three of these components)
AND
- 4 elements of the HPI (character, onset, location, duration, associated signs etc. OR the status of 3 chronic medical conditions. AND
- 10 review of systems. AND
- 3 areas from Past Medical, Medications, Allergies, Family, Social history
Exam
- 1995 rules state you need documentation in 8 or more systems. Your different systems are as follows: constitutional/vitals, eyes, ears/nose/mouth/throat, cardiovascular, respiratory, gastrointestinal, genitourinary, integumentary/skin/breasts, musculoskeletal, neurological, hematological/lymphatic/immunological, endocrine and psychiatric. 1997 rules state you need documentation in 9 areas with at least 2 bullet points in each. Your different options for areas are: general, eyes, ears/nose/mouth/throat, neck, respiratory, cardiovascular, chest/breasts, gastrointestinal/abdomen, genitourinary, lymphatic, musculoskeletal, skin, neurologic, mental status. Indicating "Normal" is acceptable. Saying "abnormal" must be clarified,
AND
Decision Making
- Diagnosis: 3 points
- Data: 3 points
- Risk: moderate
For the Decision making component, remember, you need the highest two out of three from diagnosis, data and risk.
So here is a clinical example of a mid level hospital consult CPT® 99254:
Reason for Consult: Red leg
HPI: 28 yo Male with 3 day history left calf pain. 6/10, dull, constant. Associated edema, erythema.
PMH: No chronic medical conditions. No FH of immunological disorders. Smoker.
Exam: 120/80 85 102.7 temp, well appearing
Eyes: Normal
ENT: Normal
Respiratory: Normal
Cardiovascular: Normal
Lymphatic: Normal
Neurological: Normal
Skin: erythema lines marked and noted, induration present
Mental status: Normal
ENT: Normal
Respiratory: Normal
Cardiovascular: Normal
Lymphatic: Normal
Neurological: Normal
Skin: erythema lines marked and noted, induration present
Mental status: Normal
ROS: A complete review of systems was obtained, and in the absence of the findings indicated above, all other systems are otherwise negative.
Lab: WBC 19K (1 point)
Lab: WBC 19K (1 point)
Plan
Reviewed case details with Dr Happy, hospitalist (2 points). Recommend arterial doppler exam (1 point). Start PCA narcotics for pain (HIGH RISK).
That's all you need folks. A very straight forward mid-high level CPT® 99254 hospital consult. Several things to note.
As any great hospitalist knows, what CPT® code you bill is entirely dependent on how you document, not how much you document. In this case, you can fully document a CPT® 99254 with out writing a novel. It's not how much you write, it's what you write that matters.
With the help of my E/M bedside reference cards, based on CMS guidelines, you can use them as reminder systems to document work you've already done and make sure you're getting paid appropriately for the work you've provided. Get yours today and start collecting tens of thousands of dollars a year for money you're leaving on the table because you just don't know the rules and are overwhelmed with fear of overcoding. Stop living in fear. I'm giving you the rules at the bedside, on the go, for $10 and change. It doesn't get any better than that.
With the help of my E/M bedside reference cards, based on CMS guidelines, you can use them as reminder systems to document work you've already done and make sure you're getting paid appropriately for the work you've provided. Get yours today and start collecting tens of thousands of dollars a year for money you're leaving on the table because you just don't know the rules and are overwhelmed with fear of overcoding. Stop living in fear. I'm giving you the rules at the bedside, on the go, for $10 and change. It doesn't get any better than that.
LINK TO E/M POCKET REFERENCE CARD POST
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