CPT® 99253: Detailed Explanation of Mid (Level 3) Consult Initial Inpatient Hospital Code.

If you've found this post, you're looking for information on how to bill CPT® 99253, the inpatient hospital consult E&M code.  This is 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,  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 for inpatient initial evaluations.   Some insurance still pay for consult codes and that's what you're here to learn about this code.

If you haven't seen my other hospitalist 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, click on the above link and make sure to check out my other free lectures on the inpatient hospital follow up CPT® codes 99231-99233, initial hospital inpatient admission codes CPT® 99221-99223, initial hospital observation admission codes  CPT® 99218-99220 and the same day admit/discharge CPT® codes 99234-99236.  You'll also find a wealth of information on critical care and discharge codes in addition to numerous posts about specific coding scenarios.  

Now it's time to learn about how to bill CPT® 99253, the mid level hospital consult code.  There are five hospital consult codes 99251-99255.    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.    I have access to links describing these resources in detail here.
How does the AMA define a CPT® 99253?  Make sure to get your copy of the AMA's CPT 2018 Standard Edition as the most up-to-date authority on CPT®  coding.  
Inpatient consultation for a new or established patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making that is of low 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) requiring admission are of low severity. Physicians typically spend 55 minutes at the bedside and on the patient's hospital floor or unit
The following is the  minimum you must do in order to qualify for a hospital consult  CPT® code 99253.  These rules are very similar to the low level hospital admission codes 99221, 99218 and 99234, but there are some subtle differences,  unlike the hospital consult codes 99254 and 99255, which require the exact same E&M criteria as their respective admit/initial hospital visit codes..   So here it is.  The 99253.  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)
  1. 4 elements of the HPI (character, onset, location, duration, associated signs etc.  OR the status of 3 chronic medical conditions.  AND
  2. 2 review of systems.  AND
  3. 1 area from Past Medical, Medications, Allergies, Family, Social history

  1. Extended exam of the affected body area and other symptomatic or related organ systems OR 6 areas (2 bullets each)  OR 2+ areas (12 bullets total).  Documenting three vitals is considered a bullet

Decision Making
  • Diagnosis: 2 points
  • Data: 2 points
  • Risk: Low
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® 99253:
Reason for Consult:  Red leg:
HPI: 28 yo Male with 3 day history left calf pain.  6/10, dull, constant.  Associated edema, erythema.
PMH: Smoker
Exam: 120/80  85  102.7 temp, well appearing
heart:  RRR without murmur, good femoral pulses
lungs:  clear to auscultation, normal effort
abdomen:  soft, no palpable liver
Skin:  erythema lines marked and noted, induration present
Musculoskeletal:  normal ROM knee, no clubbing, cyanosis
ROS:  No CP or SOB. Cardiac and pulmonary systems reviews negative.

 Reviewed case details and antibiotic choice with the ED physician.  Plan IV antibiotics.

That's all you need folks.  A very straight forward mid level CPT® 99253 hospital consult. Several things to note.  On history and physical examination,  you can write "normal"  and it constitutes a full exam of that body area.  You cannot write "abnormal"     As any great hospitalist knows, what code you bill is entirely dependent on how you document, not how much you document. In this case, you can fully document a CPT® 99253 without writing a novel.  It's not how much you write, it's what you write that matters. I use this pocket E/M reference card below I created to assist me with all my bedside coding needs.  


EM Pocket Reference Cards Using Marshfield Clinic Point Audit

Click image for high definition view

Print Friendly and PDF