Originally published March 4, 2020. Inpatient E/M codes were revised in 2023, and 99251 was deleted. Payer rules change; confirm current CMS and payer requirements before billing.
Inpatient billing can be confusing.
First, inpatient codes are not based on patient status. New or established status does not apply to inpatient codes, which are used for the initial visit whether or not the practitioner has an existing relationship with the patient.
Second, Medicare Part B no longer recognizes the initial consultation codes 99251–99255, although many non-Medicare payers that don't follow Medicare guidelines still accept them.
Medicare doesn't accept 99251–99255. Use 99221–99223 instead.
Initial hospital care codes
The correct codes for a first inpatient evaluation are 99221–99223. They are used for the inpatient history and physical (H&P) and for any specialty consultation, limited to one initial visit per specialty. In the past, 99221–99223 were only for the admitting physician and 99251–99255 were for consultants. Medicare dropped the consultation codes because of discrepancies between consulting fees and the criteria for those services, so consultants now also use 99221–99223.
The level of the initial admitting code reflects all services leading to the admission. E/M services provided in the office, emergency room or nursing facility on the same date as the admission are considered part of the initial hospital care.
The requirements for 99221–99223 are higher than for 99251–99255, and the E/M level must account for visit length and complexity of decision-making.
For Medicare and non-Medicare payers alike, only one initial inpatient code can be billed per specialty. Additional claims will be denied. Subsequent hospital visits are billed with 99231–99233.
Initial hospital visit codes for Medicare
- 99221: 30 minutes at the bedside, comprehensive H&P, low-complexity decision-making
- 99222: 50 minutes at the bedside, comprehensive H&P, moderate-complexity decision-making
- 99223: 70 minutes at the bedside, comprehensive H&P, high-complexity decision-making
Inpatient consultation codes for non-Medicare payers
- 99251: minor conditions, 20 minutes, problem-focused history and exam, straightforward decision-making
- 99252: low-severity conditions, 40 minutes, expanded problem-focused history and exam, straightforward decision-making
- 99253: moderate-severity conditions, 55 minutes, detailed history and exam, low-complexity decision-making
- 99254: moderate-to-high severity, 80 minutes, comprehensive history and exam, moderate-complexity decision-making
- 99255: moderate-to-high severity, 110 minutes, comprehensive history and exam, high-complexity decision-making
Required documentation for a consultation
- A verbal or written request from the referring physician
- The consulting physician's opinion or recommendations
- A written report of each service performed or ordered on the consultant's advice
- The expertise requested is outside the requesting physician's specialty