General Surgery Coding Alert

Question: If I report 99255 more than once for the same patient on different days, Medicare does not pay, stating that this is a "duplicate procedure." Is my carrier processing the claim correctly?

Oregon Subscriber

Answer: The descriptor for 99255 (Initial inpatient consultation for a new or established patient ...) clearly indicates "initial" inpatient consultation, and CPT further says, "Only one initial consultation should be reported by a consultant per admission." In other words, Medicare is correct in this case.
 
If your physician sees the same patient several times during a single hospital stay, you may report 99255 only for the first consult. You must report any subsequent consults with the same patient during the same hospital stay using one of the available follow-up inpatient consult codes (99261-99263), if the physician meets the consultation requirements (request, reason, response). If the physician provides concurrent, rather than consultative, care, use codes for subsequent inpatient care (99231-99233) with modifier   -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).
 
But if your physician provides an initial consult for two different inpatient stays for the same patient (for instance, the patient is admitted on Sept. 1, leaves on Sept. 4 and is readmitted on Sept. 6), you may report another initial inpatient consult for the second admission. In this case, you may have to show a new admission date and explain that the patient was readmitted and that the subsequent service was indeed a "new" inpatient consult rather than a follow-up consult during the same admission.