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Level 5 Hospital Consult (99255)

The 99255 represents the highest level of care for hospital consults.  Internist used the 99255 to bill for 22.2% of hospital consults in 2003.  To get an idea of the frequency of use of this code among sub-specialists, nephrologists used this level of care for 25.7% of consults performed in the hospital during that same year.  The 99255 ranked 79th among the most frequently used CPT codes by all physicians in 2003.  Usually the presenting problems are of moderate to high severityThe reimbursement for this level of care is approximately $192.10. 

The documentation for this encounter requires THREE out of THREE of the following :

1) Comprehensive History
2) Comprehensive Exam
3) High Complexity Medical Decision-Making

Or 110 minutes spent face-to-face with the patient if coding based on time.  The appropriate documentation must be included.

Clinical Example

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


Basic Course Preview
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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