Tags: coding/cpt consultation inpatient em
Overview
Consultation codes are reported when a physician or other qualified health care professional (QHP) is asked by another provider to render an opinion or advice regarding evaluation/management of a specific clinical problem — not to assume ongoing management of the patient.
Inpatient/Observation Consultation Codes (2026)
| CPT | MDM Level | Total Time (date of encounter) |
|---|---|---|
| 99252 | Straightforward | ≥35 min |
| 99253 | Low | ≥45 min |
| 99254 | Moderate | ≥60 min |
| 99255 | High | ≥80 min |
99251 Deleted
99251 (straightforward, formerly the lowest level) was deleted effective 1/1/2023 as part of the E/M revision. Code selection now starts at 99252.
Medicare Does Not Pay
Consultation Requirements (Non-Medicare)
The 3 R’s
- Request: Written or verbal request from another provider, documented in the chart
- Render: Provide opinion/recommendations
- Report: Written communication back to the requesting provider
Documentation Elements
| Element | Requirement |
|---|---|
| Request | Who requested the consult, and why |
| Opinion | Clear assessment and recommendations |
| Report | Documented communication back to requesting provider |
When to Use Consult vs. E/M
| Scenario | Code Type |
|---|---|
| Transfer of Care | Initial Hospital/Observation Care |
| Opinion Only | Consultation (if payer recognizes) |
| Co-Management | Subsequent Hospital Care |
| Medicare Patient | Initial/Subsequent Hospital Care (never consult) |
Emergency Room Consults
Consultations can be billed int he emergency room but specialists typically must use Emergency Department visit codes (99281-99285) rather than traditional consultation codes. Most insurance payers and Medicare do not accept separate outpatient or inpatient consultation codes for patients evaluated and discharged in the emergency room. Instae, billing rules require specific guidelines to be met.
Payer-Specific Recognition — Verify Before Billing
| Payer | Consultation Codes Recognized? | Notes |
|---|---|---|
| Medicare | No (since 2010) | Use 99221–99223 or 99231–992331 |
| Wisconsin Medicaid (BadgerCare Plus) | Historically yes, at reduced rate | 80% of standard fee schedule effective 5/1/2012;2 confirm current ForwardHealth fee schedule hasn’t since aligned with Medicare |
| UnitedHealthcare (commercial/exchange) | No | Denies 99242–99245 and 99252–99255; bill appropriate E/M3 |
| Cigna | No (since 10/19/2019) | Denies consult codes; resubmit with non-consultative E/M4 |
| BCBS plans (general trend) | Increasingly no | Several BCBS plans (e.g., BCBS NM 9/1/2024) have dropped reimbursement;5 confirm current BCBS of WI policy directly — not yet verified for this payer |
| UMR | Not confirmed | UMR is a UnitedHealth Group TPA; plan-level policy may follow UHC’s stance above — verify per specific group plan |
| Aetna | Not confirmed | No current policy verified in this pass — check Aetna’s Clinical Payment/Coding Policy before billing |
Practical Reality
The commercial-payer trend since ~2019–2024 has been near-universal alignment with Medicare’s non-recognition policy. When a payer isn’t listed above with a confirmed source, default to verifying rather than assuming the consult code will pay.
Modifiers
| Modifier | Use | Context |
|---|---|---|
| -AI | Principal physician of record | Appended to the admitting physician’s initial hospital/observation care code (99221–99223) — not to a consultation code itself — to distinguish the admitting provider from other physicians billing the same initial-care code range for the same date |
Flagging an Error From Your Original Note
Modifier -XS is an NCCI-associated modifier meaning “Separate Structure” — it’s used to bypass a procedure-to-procedure edit when two procedures are performed on distinct organs/structures. It doesn’t have a standard application to E/M consultation coding. If you were thinking of a modifier for a same-day, separately identifiable E/M service, -25 or -57 (decision for surgery) are the ones that actually apply here. Let me know if you want a modifier reference table built out for those instead.
00 Inpatient ProFee Coding MOC Inpatient E&M Codes Inpatient Modifiers