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Those pesky 99241-99245 and 99251-99255 codes that are not recognized

  1. Default Those pesky 99241-99245 and 99251-99255 codes that are not recognized
    Medical Coding Books
    I was taught in a Boot Camp last year that Medicare (and consequently more companies) are no longer recognizing 99241-99245 and 99251-99255 codes (outpatient and inpatient consultations).

    First of all, I don't fully understand why those codes are still in existence if more and more companies don't even recognize them. I've found numerous references on the internet that say:

    Medicare no longer pays physicians for consultations using the CPT consultation codes (99241-99245 for office or other outpt codes and 99251-99255 for inpt consults). Instead CMS instructs physicians to bill using new or established patient codes.

    The two physicians I work for (general surgeon and urologist) typically will see a patient in the hospital on consult from an ER doc or attending doc. Neither specialty will typically admit a patient.

    However, under "New or Established Patient" under Initial Hospital Care in the CPT book, it states, "For initial inpatient encounters by physicians other than the admitting physician, see initial inpatient consultation codes (99251-99255) or subsequent hospital care codes (99231-99233) as appropriate." Obviously, we can't use 99251-99255, as stated by Medicare and now numerous other insurance companies, and we are starting to see 99221-99223 being denied.

    Also, under "New or Established Patient" under Initial Observation Care in the CPT book, it states, "...For observation encounters by other physicians, see Office or Other Outpatient Consultation codes (99241-99245) or subsequent consultation care codes (99224-99226) as appropriate." Since 99241-99245 cannot be used, we must use 99224-99226, and those codes are now being denied.

    I really hope I'm explaining this sufficiently :/

    What is everyone using to code hospital consults, both observation consults and inpatient consults, and are they being denied? This is confusing, since I feel the CPT book is talking in a circle (see "this code," but "this code" refers you to "that code," but "that code" can't be used, according to Medicare). I almost dread seeing any hospital consult cross my desk.

    Thanks for your help!

  2. #2
    Nashville AAPC Chapter
    You're right it is very confusing. You must realize that Medicare does not follow the CPT rules across the board. They make their own rules to fit their payment requirements. Thus the elimination of consultation codes and billing the 69210 only once regardless of the CPT guidelines.

    So if your providers are consultants, they would bill the appropriate codes based on the situation(s):
    ER setting- either an ER code or New/established outpatient clinic codes
    Inpatient setting -
    -If they are not the admitting physician, they should use the 99221-99223 but only if the admitting physician puts and AI modifier on their admission code.
    -Then you will be limited to the 99231-99233 codes (in the case of a denial)

    Outpatient Observation status
    - Only one provider can bill OBS codes (the admitting provider) so a consultant would follow outpatient clinic codes based on the patients New/established status with the provider (99212 - 99205)


  3. #3
    Many payers still accept consult codes, and some Medicaid ones do as well. Remember that the AMA writes the CPT book and codes, not the government, and they never agree on anything
    Regional Director, Audit Services

    2015-2018 AAPC National Advisory Board Member

  4. Default
    Quote Originally Posted by LoriCox View Post
    Remember that the AMA writes the CPT book and codes, not the government, and they never agree on anything
    Isn't that the truth??

    Thank you both for your help!!

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