Reporting Inpatient Hospital Evaluation and Management (E/M) Services that Could be Described by Current Procedural Terminology (CPT) Consultation Codes

This message is to clarify proper reporting in Calendar Year (CY) 2010 of initial E/M services provided by physicians (and other qualified nonphysicians when permitted) in the inpatient hospital setting that could be described by CPT Consultation Codes (99251-99255) that are no longer recognized for payment under the Medicare Physician Fee Schedule (MPFS).  The Centers for Medicare & Medicaid Services (CMS) previously instructed physicians and other providers to use other applicable CPT E/M Codes to report the services that could be described by CPT Consultation Codes.  The CMS also provided that, in the inpatient hospital setting, physicians (and qualified nonphysicians) who perform an initial E/M service may bill the initial hospital care CPT Codes (99221 – 99223).  Since that instruction, CMS has received inquiries specifically as relates to reporting initial hospital care services for which the minimum key component work and/or medical necessity requirements for CPT Codes 99221–99233 are not documented.  For instance, one element of inpatient consultation CPT Codes 99251 and 99252, respectively, require “a problem focused history” and “an expanded problem focused history.”  In contrast, initial hospital care CPT Code 99221 requires “a detailed or comprehensive history.” 

First, CMS reminds providers that CPT Code 99221 may be reported for an E/M service if the requirements for billing that code, which are greater than CPT Consultation Codes 99251 and 99252, are met by the service furnished to the patient.  The CMS has alerted Medicare

Administrative Contractor Audit Staffs as well as Medicare Recovery Audit Contractors of its expectation that physicians may bill more E/M Codes for initial hospital care, in place of billing inpatient CPT Consultation Codes.  The CMS has also alerted contractors to expect a different proportion of various initial hospital care CPT Codes under the new policy.  The CMS expects its contractors to consider that these may be appropriate changes when making decisions about whether to pursue medical review and other types of claims review. 

Second, CMS notes that subsequent hospital care CPT Codes 99231 and 99232, respectively, require “a problem focused interval history” and “an expanded problem focused interval history” and could potentially meet the component work and medical necessity requirements to be reported for an E/M service that could be described by CPT Consultation Code 99251 or 99252.   The CMS has instructed contractors to not find fault with providers who report a subsequent hospital care CPT Code, in cases where the medical record appropriately demonstrates that the work and medical necessity requirements are met for reporting a subsequent hospital care code (under the level selected), even though the reported code is for the provider's first E/M service to the inpatient during the hospital stay

Finally, only in the case when an E/M service that could be described by CPT Code 99251 or 99252 is furnished and there is no other specific E/M code payable by Medicare that describes that service shall CPT Code 99499 (Unlisted evaluation and management service) be reported.  Reporting 99499 requires submission of medical records and contractor manual medical review of the service prior to payment, and CMS expects reporting under these circumstances to be unusual. 

While CMS expects that the CPT Code reported accurately reflects the service provided, CMS has instructed contractors to not find fault with providers who report a subsequent hospital care CPT Code, in cases where the medical record appropriately demonstrates that the work and medical necessity requirements are met for reporting a subsequent hospital care code for an initial hospital E/M service.

Refr: JSM-10152

Page last updated: February 25, 2010

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