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Hospital Consults (99251-99255)

As of January 1, 2010, MEDICARE no longer pays inpatient (or outpatient) consults.

To view a 3-minute video on how hospital consults should now be coded, click HERE

To download our CONSULT ALGORITHM and fact sheet in PDF format, click HERE

These codes are used to report hospital consults for new or established patients.  Internists performed a total of 1,576,466 of these services in 2003.  A consult is provided by a physician whose opinion or advice is requested by another physician about a specific clinical problem or issue.  Consultations may also be requested by nurse practitioners or physician assistants.  The name of the requesting clinician and the reason for the consultation must be recorded in the documentation.  The results and recommendations of the consult must be sent to the requesting physician.  In the hospital, documentation of the consult on the patient’s chart satisfies this requirement.  Do not use these codes to report a consult initiated by a patient or a family member.  (These services are reported using the separate codes for confirmatory consultations.)  If the consulting physician assumes partial care of the patient after the initial consultation, those additional services are reported as hospital progress notes--NOT as follow-up consultation services.  There are five levels of care for this type of encounter which all require the qualifying documentation of three out of three key components

Level E/M Code History Physical Exam MDM Time
1 99251 Problem Focused Problem Focused Straightforward 20
2 99252 EPF EPF Straightforward 40
3 99253 Detailed Detailed Low 55
4 99254 Comprehensive Comprehensive Moderate 80
5 99255 Comprehensive Comprehensive High 110

For these encounters, documentation of three out of three key components is required for any given level of care


This topic is covered in more detail in of one of our web-based E/M coding courses.

E/M Consult Services

Consult Services   Related Topics


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Although Medicare no longer pays for consult services, some private payers still do. But beware. Auditors love to downcode these visits when doctors don't include the exact right terminology. Learn to get it right.  
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