The Admission Consult

When consultation services occur in inpatient and outpatient settings, physicians report the code category that best corresponds to the patient’s registered status at the time of service:

Inpatient consultation (99251-99255) for services provided to an inpatient (acute care, inpatient rehabilitation, inpatient psychiatric, long-term acute care, or skilled nursing); or
Outpatient consultation (99241-99245) for services provided to an outpatient (office, emergency department [ED], or observation care).

Regardless of location, consultants must meet each requirement before submitting a claim for these services. This article focuses on the coding and billing nuances of inpatient consultation services; outpatient consultations provided in the ED or during observation care will be addressed in a future issue.

Code of the Month

ADMISSION CONSULTS

99251: Inpatient consultation, which requires these three key components:

A problem-focused history;
A problem-focused examination; and
Straightforward medical decision-making.

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 presenting problem(s) are self-limiting or minor. Physicians typically spend 20 minutes at the bedside and on the patient’s hospital floor or unit.

99252: Inpatient consultation, which requires these three key components:

An expanded problem-focused history;
An expanded problem-focused examination; and
Straightforward medical decision-making.

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 presenting problem(s) are of low severity. Physicians typically spend 40 minutes at the bedside and on the patient’s hospital floor or unit.

99253: Inpatient consultation, which requires these three key components:

A detailed history;
A detailed examination; and
Medical decision-making 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 presenting problem(s) are of moderate severity. Physicians typically spend 55 minutes at the bedside and on the patient’s hospital floor or unit.

99254: Inpatient consultation, requires three 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 presenting problem(s) are of moderate to high severity. Physicians typically spend 80 minutes at the bedside and on the patient’s hospital floor or unit.

99255: Inpatient consultation, which requires these three 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 presenting problem(s) are of moderate to high severity. Physicians typically spend 110 minutes at the bedside and on the patient’s hospital floor or unit.

These codes are used for new or established patients (those who have received face-to-face services from a physician or someone from the physician’s group within the past three years). The physician does not have to spend the associated “typical” visit time with the patient in order to report an initial hospital care code. Time is only considered when more than 50% of the total visit time is spent counseling/coordinating patient care. See Section 30.6.1C, www.cms.hhs.gov/manuals/downloads/clm104c12.pdf for more information about reporting visit level based on time.

The Three R’s

Reason and request: Consultants (physicians or qualified non-physician providers) are asked to give an opinion or recommendation, a suggestion, direction, or counsel in the treatment of a patient’s condition because the consultant has expertise in a specific medical area beyond the requesting professional’s knowledge.

The Admission Consult

Code of the Month

The Three R’s

The Admission Consult

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