Summary & Overview
CPT 99251: Inpatient Consultation, Problem Focused Evaluation
CPT code 99251 represents an inpatient consultation for new or established patients, requiring a problem focused history, examination, and straightforward medical decision making. This code is significant nationally as it defines the scope and complexity of physician consultations within hospital settings, impacting both clinical workflows and billing practices. The publication covers major payers including Blue Cross Blue Shield, Cigna Health, and UnitedHealthcare, providing insights into payer coverage and policy nuances for this consultation service.
Readers will gain a comprehensive understanding of the clinical context for CPT code 99251, including its role in hospital-based care and how it differentiates from other evaluation and management codes. The summary includes benchmarks, policy updates, and relevant clinical scenarios, such as consultations for chest pain, pneumonia, urinary tract infection, hypertension, and diabetes. The article also highlights common modifiers and associated provider taxonomies, offering a clear overview of how this code is utilized in practice. This information is essential for healthcare professionals, administrators, and policy analysts seeking to stay informed about inpatient consultation coding and reimbursement trends.
CPT Code Overview
CPT code 99251 is used to report an inpatient consultation for a new or established patient. This service requires three key components: a problem focused history, a problem focused examination, and straightforward medical decision making. The typical site of service for this consultation is the inpatient hospital setting, specifically Place of Service 21. This code is designed for situations where a physician is requested to provide their expert opinion or advice regarding a patient's condition during a hospital stay.
Clinical & Coding Specifications
Clinical Context
A patient is admitted to the inpatient hospital setting (Place of Service 21) with a new or established medical concern. The attending physician requests a consultation from a hospitalist, internal medicine physician, or general practice physician. The consulting provider performs a problem-focused history and examination, and engages in straightforward medical decision making. Common clinical scenarios include evaluation for chest pain, pneumonia, urinary tract infection, hypertension, or type 2 diabetes mellitus without complications. The consultation is documented and communicated to the requesting provider as part of the inpatient care team workflow.
Coding Specifications
-
Modifiers:
-
Modifier
25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service. Used when the consultation is distinct from other services provided on the same day. -
Modifier
57: Decision for Surgery. Used when the consultation results in the decision to perform surgery.
-
-
Provider Taxonomies:
Taxonomy Code Specialty Name