Summary & Overview
CPT 99251: Inpatient Consultation, Problem Focused Evaluation
CPT code 99251 represents an inpatient consultation for new or established patients, requiring a problem focused history, examination, and straightforward medical decision making. This code is significant nationally as it defines the scope and complexity of physician consultations within hospital settings, impacting both clinical workflows and billing practices. The publication covers major payers including Blue Cross Blue Shield, Cigna Health, and UnitedHealthcare, providing insights into payer coverage and policy nuances for this consultation service.
Readers will gain a comprehensive understanding of the clinical context for CPT code 99251, including its role in hospital-based care and how it differentiates from other evaluation and management codes. The summary includes benchmarks, policy updates, and relevant clinical scenarios, such as consultations for chest pain, pneumonia, urinary tract infection, hypertension, and diabetes. The article also highlights common modifiers and associated provider taxonomies, offering a clear overview of how this code is utilized in practice. This information is essential for healthcare professionals, administrators, and policy analysts seeking to stay informed about inpatient consultation coding and reimbursement trends.
CPT Code Overview
CPT code 99251 is used to report an inpatient consultation for a new or established patient. This service requires three key components: a problem focused history, a problem focused examination, and straightforward medical decision making. The typical site of service for this consultation is the inpatient hospital setting, specifically Place of Service 21. This code is designed for situations where a physician is requested to provide their expert opinion or advice regarding a patient's condition during a hospital stay.
Clinical & Coding Specifications
Clinical Context
A patient is admitted to the inpatient hospital setting (Place of Service 21) with a new or established medical concern. The attending physician requests a consultation from a hospitalist, internal medicine physician, or general practice physician. The consulting provider performs a problem-focused history and examination, and engages in straightforward medical decision making. Common clinical scenarios include evaluation for chest pain, pneumonia, urinary tract infection, hypertension, or type 2 diabetes mellitus without complications. The consultation is documented and communicated to the requesting provider as part of the inpatient care team workflow.
Coding Specifications
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Modifiers:
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Modifier
25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service. Used when the consultation is distinct from other services provided on the same day. -
Modifier
57: Decision for Surgery. Used when the consultation results in the decision to perform surgery.
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Provider Taxonomies:
Taxonomy Code Specialty Name 208M00000XHospitalist 207R00000XInternal Medicine Physician 208D00000XGeneral Practice Physician
These taxonomies represent the specialties commonly performing inpatient consultations.
Related Diagnoses
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R07.9— Chest pain, unspecified- Relevant for consultations addressing acute or unclear chest pain in the inpatient setting.
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J18.9— Pneumonia, unspecified organism- Used when the consultation is for evaluation and management of pneumonia without a specified causative organism.
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N39.0— Urinary tract infection, site not specified- Applicable for inpatient consultations regarding urinary tract infections where the site is not specified.
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I10— Essential (primary) hypertension- Used for consultations related to the management of primary hypertension in hospitalized patients.
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E11.9— Type 2 diabetes mellitus without complications- Relevant for consultations addressing diabetes management without complications during inpatient admission.
Related CPT Codes
| CPT Code | Description |
|---|---|
99221 | Initial hospital care, per day, for the evaluation and management of a patient |
99231 | Subsequent hospital care, per day, for the evaluation and management of a patient |
99238 | Hospital discharge day management; 30 minutes or less |
99241 | Office consultation for a new or established patient |
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99221is used for initial hospital care and may follow an inpatient consultation (99251) if the consultant assumes care. -
99231is used for subsequent hospital care visits after the initial consultation or admission. -
99238is used for discharge day management, typically at the end of an inpatient stay. -
99241is an office consultation code, used in outpatient settings and not typically billed in the inpatient context.
These codes are related in the clinical workflow of inpatient evaluation, management, and transitions of care.
National Reimbursement Benchmarks
Nationally, the mean rate for CPT code 99251 among commercial payers (BUCA) is $79.83, while Medicare rates are not available in the input. Blue Cross Blue Shield, UnitedHealth Group, and Cigna all show higher mean rates than BUCA, with Cigna notably higher at $142.99.
Rate dispersion varies significantly across payers. Cigna exhibits the tightest range, with all percentile values at $143.00, indicating no variation. Blue Cross Blue Shield and UnitedHealth Group display wider ranges, with BCBS spanning $33.31 between the 25th and 75th percentiles, and UHC spanning $39.67. The table and chart below present the full breakdown of national benchmarks for CPT code 99251 by payer.
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