Inpatient billing can be confusing.
The first aspect to understand is that it is not based on the status of the patient. New or established status does not apply to inpatient billing codes, as they are used for an initial doctor visit, whether the practitioner has an established relationship with the patient.
Second, the old initial consultation codes (99251-99255) are no longer recognized by Medicare Part B, although many non-Medicare providers still use them if the payer doesn’t follow Medicare guidelines.
Medicare doesn’t accept codes (99251-99255) use (99221-99223) instead
The correct inpatient consultation codes for a first evaluation are 99221-99223. These codes are used for the inpatient History and Physical (H & P), as well as any specialty consultation (limited to one visit from each specialty). In the past, the codes 99221-99223 were used only for the admitting physicians, and the codes 99251-99255 were designated for consulting physicians. The consulting physician codes were dropped from Medicare guidelines due to discrepancies in paid consulting fees and the proper criteria required for those services. The new guidelines require consulting providers also to use 99221-99223.
When determining the appropriate level of the initial admitting code, the same requirements apply as before. All services performed in an office and the resulting hospital admission are reflected (i.e., admission following any evaluation and management (E/M) services received by the patient in an office, emergency room, or nursing facility). If these services are on the same date as admission, they are considered part of the initial hospital care.
The requirements for codes 99221-99223 are more significant than for 99251-99255, and the E/M services levels must be met, taking into account the length of the visit and depth of decision making.
No matter whether billing for Medicare or a non-Medicare provider, only one inpatient initial code can be billed for each specialty. Additional submissions will be denied. Subsequent hospital visits should be coded using 99231-99233 (not discussed explicitly in this writing).
Billing CPT Codes for Inpatient Initial Hospital Visits to Medicare:
99221:
- 30 minutes bedside
- First inpatient encounter narrative
- Comprehensive H & P
- Low-level medical decision-making
99222:
- 50 minutes bedside
- Comprehensive H & P
- Moderate-level medical decision-making
99223:
- 70 minutes bedside
- Comprehensive H & P
- High-level medical decision-making
Billing CPT Codes for Consulting Inpatient Initial Hospital Visits Outside of Medicare Guidelines
99251:
- Typically minor conditions
- 20 minutes bedside
- Problem-focused medical history
- Problem-focused exam
- Straightforward medical decision-making
99252:
- Low-severity conditions
- 40 minutes bedside
- Expanded problem-focused medical history
- Expanded problem-focused exam
- Straightforward medical decision-making
99253:
- Moderate-severity conditions
- 55 minutes bedside
- Detailed medical history
- Detailed exam
- Low-complexity medical decision-making
99254:
- Moderate-to-high-severity conditions
- 80 minutes bedside
- Comprehensive history
- Comprehensive exam
- Moderate-complexity medical decision-making
99255:
- Moderate-to-high-severity conditions
- 110 minutes bedside
- Comprehensive history
- Comprehensive exam
- High-complexity medical decision-making
The required documentation for a consulting visit includes:
- A request (verbal or written) from the referring physician
- The specific opinion or recommendations of the consulting physician
- A written report of each service performed or ordered on the advice of the consulting physician
- The medical expertise requested is beyond the specialty of the requesting physician