Neurology & Pain Management Coding Alert

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

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. Therefore, 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 may have to show a new admission date and explain that the patient was re-admitted to clarify to the insurer that the subsequent service was indeed a new inpatient consult rather than a follow-up consult during the same admission.