Inpatient Consultations

Reimbursement Policy:
Inpatient Consultations

Effective Date:
April 4, 2012

Last Revised Date:
January 27, 2020

Purpose:
To provide guidelines for the reimbursement of procedure codes for Inpatient Consultations (99251-99255) and Telehealth Consultations (G0508-G0509), without matching on diagnosis codes billed.

Scope:
All products are included, except

Products where Horizon BCBSNJ is secondary to Medicare (e.g. Medigap).
COB

All Insured and Administrative Services Only (ASO) accounts are included.

Definitions:
A Consultation is a service delivered by a physician, at the request of another physician, to recommend care for a condition or to decide if the physician is going to accept responsibility for continued management of the patient’s care or for the care of a precise condition. If the consulting physician accepts responsibility of all or part of the patient’s condition, the correct E&M code for the site of service must be reported.

Policy:

Horizon BCBSNJ shall reimburse only one inpatient or telehealth consultation per facility admission for the same patient when submitted by the same physician regardless of diagnosis codes billed.
Horizon shall not separately reimburse for an office Evaluation & Management (E&M) when the patient is admitted to the hospital from the physician’s office. All E&M services provided by the physician in conjunction with the admission are considered part of the initial hospital care when performed on the same date as the admission.

CPT Code	Key Components	Presenting Problem	Time spent at patient's bedside/hospital floor
99251	Problem focused history Problem focused examination straightforward medical decision making	Self-limited or Minor	20
99252	Expanded problem focused history Expanded problem focused examination straightforward medical decision making	Low Severity	40
99253	Detailed history Detailed examination Low complexity medical decision making	Moderate Severity	55
99254	Comprehensive history Comprehensive examination Moderate complexity medical decision making	Moderate to High Severity	80
99255	Comprehensive history Comprehensive examination High complexity medical decision making	Moderate to High Severity	110

Procedure:

Only one inpatient or telehealth consultation code shall be paid per facility admission,. Other inpatient consultation codes shall be denied when billed by the same provider, for the same member, regardless of the diagnosis codes billed.
The appropriate subsequent hospital care E & M code(s) should be reported by the provider.
Reimbursements will be based off provider/member contracts.
There shall be no member liability when the provider is participating.
When provider is non-participating, the member’s liability shall be up to the provider’s charge.

Limitations and Exclusions:

While reimbursement is considered, payment determination is subject to, but not limited to:

Group or Individual benefit
Provider Participation Agreement
Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
Mandated or legislative required criteria will always supersede.

History:

8/2/2012: Policy approved.
7/28/14: Removed requirement for diagnosis code match.
1/27/2020: Added telehealth consultations.

CPT® is a registered mark of the American Medical Association

Policy 064_v1.0_01272020