Medicare Compliance & Reimbursement

Question: What is the difference between an office consultation and an inpatient consultation? When should we use each code set?

Codify Subscriber

Answer: You would use the codes depending on the patient’s hospital status at the time of the consultation.

According to CPT^® 2019, you should report inpatient consults when “an inpatient consultation is performed on a date that the patient is admitted to a hospital or nursing facility.”

You would report inpatient consults with codes from 99251 (Inpatient consultation for a new or established patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making) through 99255 (… A comprehensive history; A comprehensive examination; and Medical decision making of high complexity …), depending on encounter specifics.

Reminder: You’ll use the inpatient consult codes for “all evaluation and management services provided by the consultant related to the admission,” according to CPT^® 2019.

If, however, the consult occurs after “a patient is admitted after an outpatient consultation (office, emergency department, etc.), and the patient is not seen on the unit on the date of admission,” you’d report the office consult codes, according to CPT^® 2019.

You would report office consult services with codes from 99241 (Office consultation for a new or established patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making …) through 99245 (… A comprehensive history; A comprehensive examination; and Medical decision making of high complexity …), depending on encounter specifics.