Determining A Consult Level


Best answers
Hi all,

I'm a little confused when it comes to determine the level for a consult and also for inpatient.

For a consult, I know 3 of 3 have to be met. If you have a C History , C Exam and H MDM, what would the level be?

For an inpatient, I know 3 of 3 must be met. But if they are not, and say you have a D/C History D/C Exam and M. MDM, how do you determine what the level is?

How about subsequent hospital (even though 2 are needed)?

I've had to teach myself all of this and have learned alot but these three instances confuse me.

TIA for any help,


NAB Member
New London, MO
Best answers

E&M levels can be tricky if you are new to them. I would suggest getting a really good audit tool to assist you.

For your consult example, this would be a 99245/99255, because you have met the 3 required elements. Remember that Medicare doesn't pay these. In addition, you should be sure that the medical necessity requires this high of a visit - a patient with a simple cold would not be a level 5.

For the inpatient, for the initial hospital care, you would bill 99222. You can't bill a 99223 because your MDM is not high.

For subsequent hospital care, you only need to meet 2 of the elements. So if you have a EPF history and EPF exam, and a Low MDM, you should still bill a 99232 because you have met the 2 elements needed. Some payers and facilities require the MDM to be 1 of the 2 elements however, so if that were the case and you have to use MDM as one of the 2, then you would have to bill a 99231 for this example.

Go to the highest level and work your way backwards until all your required elements are met.

Hope that helps!