Inpatient Consultations

Reimbursement Policy:
Inpatient Consultations

Effective Date:
April 4, 2012

Last Revised Date:
July 15, 2015

Purpose:
To provide guidelines for the reimbursement of procedure codes for Inpatient Consultations for new or established patient procedure codes 99251-99255, 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:
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 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
  1. Problem focused history
  2. Problem focused examination
  3. straightforward medical decision making
Self-limited or Minor 20
99252
  1. Expanded problem focused history
  2. Expanded problem focused examination
  3. straightforward medical decision making
Low Severity 40
99253
  1. Detailed history
  2. Detailed examination
  3. Low complexity medical decision making
Moderate Severity 55
99254
  1. Comprehensive history
  2. Comprehensive examination
  3. Moderate complexity medical decision making
Moderate to High Severity 80
99255
  1. Comprehensive history
  2. Comprehensive examination
  3. High complexity medical decision making
Moderate to High Severity 110

Procedure:

  • Only one inpatient 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:

7/28/14: Removed requirement for diagnosis code match.

CPT® is a registered mark of the American Medical Association

Policy 064_v1.0_07152015