2025 CPT code 99255
(Revised) Effective Date: N/A Revision Date: N/A Evaluation and Management - Consultations Feed
Inpatient or observation consultation for a new or established patient, requiring a medically appropriate history and/or examination and high-level medical decision making (MDM).If using total time, 80 minutes must be met or exceeded.
Modifiers may be applicable.Modifier 32 is used if the consultation is mandated by a third-party payer. Other modifiers may be applicable depending on the circumstances of the service.
Medical necessity for this code must be supported by the documentation, demonstrating the complexity of the patient's condition and the need for specialized expertise in consultation.The consultant's recommendations for further treatment or management should be clearly justified based on the patient's clinical presentation and diagnostic findings.
The physician consultant provides a service that includes evaluating the patient's condition, reviewing their medical history, performing a medically appropriate examination, making complex medical decisions, and communicating the findings and recommendations to the requesting physician or other appropriate source.
In simple words: This code covers a doctor's visit for a consultation while you are in the hospital or under observation. The doctor will spend a significant amount of time with you, at least 80 minutes, to evaluate your condition, make complex medical decisions, and possibly conduct a physical exam and review your history if needed.
This code represents a consultation service provided to a new or established patient in an inpatient or observation setting. It involves a medically appropriate history and/or physical examination, along with a high level of medical decision making. The code selection can be based on either MDM or total time spent on the date of the encounter. If using total time, it must be at least 80 minutes. For services exceeding 95 minutes, use prolonged services code 99418.
Example 1: A patient is admitted to the hospital for chest pain. The attending physician requests a cardiology consultation to evaluate the patient's cardiac condition and recommend a treatment plan. The cardiologist spends over 80 minutes evaluating the patient, reviewing test results, and discussing treatment options with the patient and attending physician., A patient is under observation status for a possible stroke. The attending physician requests a neurology consultation. The neurologist performs a comprehensive neurological exam, reviews the patient's history and imaging studies, and spends over an hour discussing the diagnosis and treatment plan with the patient's family, thus meeting the criteria for 99255., A patient admitted for abdominal pain is seen by a surgical consultant who conducts a detailed history and physical exam. Several differential diagnoses are considered, requiring extensive review of the patient’s history, labs, and imaging, taking 90 minutes of the surgeon’s time. The surgeon documents the findings and recommendations in a detailed report to the referring physician.
Documentation should include a detailed written report to the requesting physician summarizing the consultant's findings, recommendations, and any services ordered or performed. It should also support the level of MDM or the total time spent on the encounter, including details of the history, examination, and medical decision-making process. The request for consultation should also be documented.
- Specialties:The specialties using this code vary widely and depend on the reason for the consultation. Examples include cardiology, neurology, surgery, oncology, and infectious disease, among others.
- Place of Service:Inpatient Hospital, Observation