CPT® 99255: Detailed Explanation of High (Level 5) Consult Initial Inpatient Hospital Code.

If you've found this post, you're looking for information on how to bill CPT® 99255, 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 them.

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 hospitalist coding lectures  on the inpatient hospital follow up CPT® codes 99231-99233.  You'll also find information on my initial hospital admission codes 99221-99223 which, as you'll find out require the exact same documentation as the observation codes 99218-99220 respectively.  Interestingly enough, these codes also require the same documentation as admit discharge same day codes 99234-99236, respectively.

Now it's time to learn about how to bill CPT® 99255, the high level hospital consult code.  There are five hospital consult codes 99251-99255.  I have never billed a 99252 or 99251.  I rarely bill 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 for the work you are already providing.

If you want to make things really simple, simply click on any of the above link for the documentation requirements of CPT® 99223, CPT® 99220 or CPT® 99236.  The evaluation and management requirements necessary for these three codes are exactly the same as those of the CPT® 99255 consult code.  Exactly the same.  99255=99223=99220=99236.  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.  Links to these resources are available in my hospitalist resource center.  
How does the AMA define a CPT® 99255?  Refer to the AMA's CPT 2018 Standard Edition as the authority in CPT® codes
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 high 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 110 minutes at the bedside and on the patient's hospital floor or unit.
The rules are highly complex.  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 99255.  As I stated above, the requirements are exactly the same as CPT® codes  99223, 99220 and 99236.  Exactly the same.  So here it is:  the 99255.   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. 10 review of systems.  AND
  3. 3 areas from Past Medical, Medications, Allergies, Family, Social history

  1. 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,

    Decision Making
    • Diagnosis: 4 points
    • Data: 4 points
    • Risk: high
    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 high level  hospital consult CPT® 99255:
    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

    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).  X Ray of the leg report reviewed:  Normal bones.  (1 point)

     Reviewed case details with Dr Happy, hospitalist (2 points).  Recommend arterial doppler exam .  Start PCA narcotics for pain (HIGH RISK).

    That's all you need folks.  A very straight forward 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® 99255 without 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 over coding.  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.   


    EM Pocket Reference Cards Using Marshfield Clinic Point Audit

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