Orthopedic Coding Alert

Question: If I report 99255 more than once for the same patient (but on different days), Medicare does not pay, stating that this is a "duplicate procedure." Should
I appeal?

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.
 
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, as appropriate).
  
If, however, your physician provides an initial consult for two different inpatient stays for the same patient (for instance, the patient is admitted on June 1, leaves on June 4 and is readmitted on June 6), you may report another initial inpatient consult for the second admission. In this case, you must show a new admission date on the claim so the payer will know 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.