CurrentArizona Complete HealthPolicy CC.PP.038

Inpatient Consultation

Defines how Arizona Complete Health evaluates and reimburses inpatient consultation CPT codes (99251-99255) and HCPCS G0406-G0408, documentation requirements, and when subsequent care codes should be billed; applies to professional and inpatient institutional claims for the same member and provider.

Policy Summary

PayerArizona Complete Health

PolicyInpatient Consultation

Policy CodePolicy CC.PP.038

Change TypeNo material change

Effective DateJan 1, 2014

Next Review Date

Key ActionDocument a written or verbal consult request from an appropriate source in the medical record and record the consultant’s opinion in the chart and a written report to the requesting physician.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5-day windowdenial interval

99251-99255, G0406-G0408consultation codes

99231-99233subsequent hospital care

99307-99310subsequent nursing facility

one consultationper admission limit

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage criteria for inpatient consultations

Reimbursement is dependent on requester/source, documentation, timing, and correct code selection for consults and follow-up care.

ALL of the following

ALL of the following
- Consult must be requested by an appropriate source and the request documented in the patient's medical record.
  Written or verbal request acceptable; must appear in chart.
- The consultant's opinion must be documented in the patient's medical record.
- The consultant's opinion must be communicated by written report to the requesting physician or other appropriate source.
ALL of the following
- Only one inpatient consultation code should be reported by a consultant per admission.
- E&M services that occur after the initial consultation during the same admission should be reported using subsequent hospital care codes (99231-99233) or subsequent nursing facility care codes (99307-99310) as appropriate, rather than additional consultation codes.
ALL of the following
- Claim lines containing an inpatient consultation procedure code billed within five days of another inpatient consultation procedure will be denied.
ALL of the following
- Do not report consultation codes for services initiated by a parent or family when not requested by a physician or other appropriate source; instead report appropriate office visit, hospital care, home service, or domiciliary/rest home care codes.
- For Medicare members, do not bill CPT consultation codes 99241-99245 and 99251-99255; report the appropriate E/M code payable under the Medicare fee schedule that reflects location and complexity of the visit.

Applicable claims: Applies to professional and inpatient institutional claims for the same member and same provider.

Consultation and subsequent care codes

Inpatient consultation codesCPT

99251	Inpatient consultation for a new or established patient (20 Min)
99252	Inpatient consultation for a new or established patient (40 Min)
99253	Inpatient consultation for a new or established patient (55 Min)
99254	Inpatient consultation for a new or established patient (80 Min)
99255	Inpatient consultation for a new or established patient (110 Min)
G0406	Follow-up inpatient consultation (15 Min)
G0407	Follow-up inpatient consultation (25 Min)
G0408	Follow-up inpatient consultation (35 Min)
99231	Subsequent hospital care, per day (15 Min)
99232	Subsequent hospital care, per day (25 Min)

1–10 of 15

1/2

Duplicate consultation interval

Duplicate consultation interval (days)5 days

Denial conditionClaim lines with an inpatient consultation code billed within five days of another inpatient consultation procedure will be denied.

ScopeApplies to inpatient consultation procedure codes billed by the same provider for the same member.

Provider billing and documentation actions

Documentation Required

Document consult request and consultant findings

Ensure a written or verbal consult request from an appropriate source is documented in the patient's medical record; document the consultant's opinion in the medical record and communicate it in a written report to the requesting physician or appropriate source.

A written or verbal request for consult must be made by an appropriate source and documented in the patient's medical record.
The consultant's opinion must be documented in the patient's medical records and communicated by written report to the requesting physician or other appropriate source.

Denial Risk

Avoid duplicate consultation billing and use subsequent care codes

Claim lines with an inpatient consultation code billed within five days of another inpatient consultation procedure will be denied; only one inpatient consultation code should be reported per admission, and subsequent inpatient care should be billed with subsequent hospital or nursing facility care codes.

Key definitions

Consultation (per AMA CPT)

Definition (AMA CPT)An evaluation and management (E&M) service provided at the request of another physician or appropriate source to recommend care for a specific condition or determine whether to accept responsibility for ongoing management.

Post-consult responsibilityIf the consultant assumes responsibility for management after the consultation, report the appropriate E&M procedure code for the location of service.

Policy purposeThis policy outlines evaluation and reimbursement of CPT consultation codes 99251-99255 and HCPCS G0406-G0408, identifying when subsequent hospital care codes should be billed.

Follow-up care

Follow-up care coding ruleE&M services after the initial inpatient consultation during the same admission should be reported using subsequent hospital care codes (99231-99233) or subsequent nursing facility care codes (99307-99310).