CPT code 99251, 99252 , 99253, 99254, 99255

Procedure code and Description

99251 Inpatient consultation for a new or established patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are selflimited or minor. Typically, 20 minutes are spent at the bedside and on the patient's hospital floor or unit.


99252 Inpatient consultation for a new or established patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low severity. Typically, 40 minutes are spent at the bedside and on the patient's hospital floor or unit.

99253 Inpatient consultation for a new or established patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. Typically, 55 minutes are spent at the bedside and on the patient's hospital floor or unit.

99254 Inpatient consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 80 minutes are spent at the bedside and on the patient's hospital floor or unit.

99255 Inpatient consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 110 minutes are spent at the bedside and on the patient's hospital floor or unit.


 Types of Consultations

CPT″ consultation codes are divided into two sections based on place of service:

A. Office or Other Outpatient Consultations:

Office or other outpatient consultations are reported with CPT″ codes 99241-99245 with no distinction between new and established patients. Consultation is appropriate in any outpatient setting including the office, emergency department, home, or domiciliary setting.

B. Inpatient Consultations:

Inpatient consultations are reported with CPT″ codes 99251-99255. The codes are used to report physician or other health care professional consultations provided to hospital inpatients, residents of nursing facilities, or patients in a partial hospital setting.


Initial and Follow-Up Consultation Services

A. Initial Consultation

1. In the hospital and nursing facility setting, the consulting physician or other qualified health care professional shall use the appropriate inpatient consultation CPT″ codes 99251-99255 for the initial consultation service. The initial inpatient consultation may be reported only once per consultant per patient per facility admission.

2. In the office or outpatient setting, the consultant should use the appropriate office or outpatient consultation CPT″ codes 99241-99245 for the initial consultation service. 3. A consulting physician or other qualified health care professional may initiate diagnostic services and treatment at the initial consultation service or may even take over the patient’s care after the initial consultation.

B. Follow-up Services

1. Ongoing management, following the initial consultation service by the consulting physician or other qualified health care professional should not be reported with consultation service codes. These services need to be reported as subsequent visits with the appropriate place of service and level of service.

2. In the hospital setting, following the initial consultation service, the subsequent hospital care CPT″ codes 99231-99233 should be reported for additional follow-up visits. In the nursing facility setting, following the initial consultation service, the subsequent nursing facility care CPT″codes 99307-99310 should be reported for additional follow-up visits.

3. In the outpatient setting, following the initial consultation service, the office or outpatient established patient CPT″ codes 99212-99215 should be reported for additional follow-up visits.

4. If an additional request for an opinion regarding the same or new problem with the same patient is received from the same or another physician or other appropriate source and documented in the medical record, the office or outpatient consultation CPT″ codes 99241- 99245 may be used again • However, if after any consultation service, the consultant then continues to care for the patient for the original condition, such follow-up services should not be reported with consultation service codes.

Medicare Guidelines for consult code 99241 - 99255 


• Follow-up visits to a consultation service in the office or other outpatient settings will be reported with the Office or Other Outpatient Established Patient codes 99212-99215.

• Beginning January 1, 2006, in a facility setting a second opinion consultation arranged through the attending physician will be reported by a physician/qualified NPP using an appropriate Initial Inpatient Consultation code when the consultation requirements are met.

• When consultation requirements are not met the Subsequent Hospital Care codes (99231-99233) in the hospital setting and the Subsequent NF Care codes (99307-99310) in the NF setting will be reported.

• In the Office or Other Outpatient setting for a second opinion evaluation, a physician/qualified NPP will use new patient codes (99201-99205) for new patients and established patient codes (99212- 99215) for an established patient, as appropriate.

• Physicians and qualified NPPs must report:

• Initial Inpatient Consultation codes (99251-99255) for an initial consultation and the inpatient hospital setting and the SNF/NF setting; and

• Appropriate Office or Other Outpatient Consultation codes (99241-99245) for and initial consultation in the office/outpatient setting.

• Following the physician’s and qualified NPP’s initial consultation service, the follow-up visits should be reported using the:

• Subsequent Hospital Care codes (99231-99233) for the inpatient hospital setting; and

• Subsequent NF Care codes (99307-99310) in the NF setting; and

• Office or Other Outpatient Established Patient codes (99212-99215) should be reported for the office/outpatient setting.



Billing with Preventive code

Preventive Medicine Services include counseling. When counseling service codes are billed with a Preventive Medicine code on the same date of service by the Same Specialty Physician, Hospital, Ambulatory Surgical Center or Other Health Care Professional, only the Preventive Medicine code is reimbursed.

Consult code replacement CPTs.

Medicare no longer accept consult code. Please find below the crosswalk replacement codes for consult code


CPT Consultative Services Code CPT E/M Codes for Crosswalking Modifier Required

99251 99221 (Inpatient Initial Visit, level 1) Yes, you will need to append Modifier “AI”

99252 99221 (Inpatient Initial Visit, level 1) or 99222 (Inpatient Initial Visit, level 2) Yes, you will need to append Modifier “AI”

99253 99222 (Inpatient Initial Visit, level 1) Yes, you will need to append Modifier “AI”

99254 99222 (Inpatient Initial Visit, level 2) or 99222 (Inpatient Initial Visit, level 3) Yes, you will need to append Modifier “AI”

99255 99223 (Inpatient Initial Visit, level 3) Yes, you will need to append Modifier “AI”



CPT code G0502, G0503,G0504, G0507 - Psychiatric managment

• G0502: Initial psychiatric collaborative care management, first 70 minutes in the first calendar month of  behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional, with the following required elements:

++ Outreach to and engagement in treatment of a patient directed by the treating physician or other qualified health care professional;

++ Initial assessment of the patient, including administration of validated  rating scales, with the development of an individualized treatment plan;

++ Review by the psychiatric consultant with modifications of the plan if recommended;

++ Entering patient in a registry and tracking patient follow-up and progress using the registry, with  appropriate documentation, and participation in weekly caseload consultation with the psychiatric consultant; and

++ Provision of brief interventions using evidence-based techniques such as behavioral activation, motivational interviewing, and other focused treatment strategies.



• G0503: Subsequent psychiatric collaborative care management, first 60 minutes in a subsequent month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional, with the following required elements:


++ Tracking patient follow-up and progress using the registry, with appropriate documentation;

++ Participation in weekly caseload consultation with the psychiatric consultant;

++ Ongoing collaboration with and coordination of the patient’s mental health care with the treating physician or other qualified health care professional and any other treating mental health providers;

++ Additional review of progress and recommendations for changes in treatment, as indicated, including medications, based on
recommendations provided by the psychiatric consultant;

++ Provision of brief interventions using evidence-based techniques such as behavioral activation, motivational interviewing, and other focused treatment strategies;

++ Monitoring of patient outcomes using validated rating scales; and relapse prevention planning with patients as they achieve remission of symptoms and/or other treatment goals and are prepared for discharge from active treatment.



• G0504: Initial or subsequent psychiatric collaborative care management, each additional 30 minutes in a calendar month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional (List separately in addition to code for primary procedure) (Use G0504 in conjunction with G0502, G0503).


Beginning in CY 2017, we are providing separate payment for BHI services furnished under models of care other than the psychiatric CoCM model, under HCPCS code G0507: Care management services for behavioral health conditions, at least 20 minutes of clinical staff time, directed by a physician or other qualified health care professional, per calendar month, with the following required elements:


• Initial assessment or follow-up monitoring, including the use of applicable validated rating scales;

• Behavioral health care planning in relation to behavioral/psychiatric health problems, including revision for patients who are not progressing or whose status changes;

• Facilitating and coordinating treatment such as psychotherapy, pharmacotherapy, counseling and/or psychiatric consultation; and

• Continuity of care with a designated member of the care team.


G0507 is reported by the treating physician or other qualified health care professional for services furnished during a calendar month service period.

Patent got HMO middle of the month - where to file a claim


Q: My patient enrolled in a Medicare Advantage (MA) plan during the middle of the inpatient hospital stay. Who should I bill?

A: When a patient enrolls or disenrolls in a MA plan during his/her inpatient stay, the following factors will determine whether to bill the MA plan and/or “traditional” Medicare:

1. The hospital provider receives prospective payment system (PPS) payments, or is exempt from PPS payments, or is a non-PPS provider; and

2. The date of enrollment/disenrollment with the MA plan

Inpatient PPS provider billing guidelines

The patient’s entitlement status at admission determines liability for inpatient acute care hospitals, inpatient rehabilitation facilities (IRFs), or long term care hospitals (LTCHs) that receive PPS payments.

If the patient was not enrolled in the MA plan at the time of admission and enrolls before discharge:

• Bill the entire inpatient stay to Medicare for payment
• MA organization is not responsible for payment

If the patient is enrolled in an MA plan at the time of admission and disenrolls before discharge:

• Bill the entire inpatient stay to MA plan for payment, and,
• Submit a no-pay claim to Medicare to report the patient’s inpatient utilization days


Exempt PPS inpatient provider billing guidelines

Providers that are inpatient children hospitals, cancer hospitals, and psychiatric hospitals/units exempt from PPS must split bill the appropriate coverage portion of the patient’s inpatient stay with Medicare and MA plan.

Example:

The patient is admitted on September 28 and discharged October 13, and enrolls in an MA plan effective October 1. Split bill as follows:

• Bill Medicare for dates of service September 28 through September 30; and,

• Bill MA plan for dates of service October 1 through October 13, and include necessary supporting documents; and

• Submit a no-pay claim to Medicare for dates of service October 1 through October 13 to report the patient’s inpatient utilization days

Non-PPS inpatient provider billing guidelines

Inpatient hospitals that do not receive PPS payments must also split bill and may only bill the MA plan for dates of service that fall within the coverage period enrollment and disenrollment dates.


Q: The claim for my patient’s dates of service overlaps a Medicare Advantage (MA) plan and hospice elections period. Should I bill the hospice, traditional Medicare or the MA plan?

A: Federal regulations require that Medicare administrative contractors (MAC) maintain payment responsibility for managed care enrollees who elect hospice.

While a hospice election is in effect, certain types of claims may be submitted to the MAC, by either the hospice provider or a provider treating an illness not related to the terminal condition. These claims are subject to the usual Medicare rules of payment, but only for the following services:

• Hospice services covered under the Medicare hospice benefit are billed by the Medicare hospice

• Institutional providers may submit claims to Medicare with the condition code “07” when services provided are not related to the treatment of the terminal condition

• MA plan enrollees that elect hospice may revoke hospice election at any time, but claims will continue to be paid by the MAC as if the beneficiary were enrolled in Medicare until the first day of the month following when hospice election was revoked

Example:

Beneficiary’s hospice election period ended on 1/10/YY
Bill the MAC for claims for dates of service 1/11/YY to 1/31/YY
Bill the MA plan for claims for dates of service 2/1/YY and beyond



Q: How do I determine if a patient is enrolled in a Medicare Advantage (MA) plan, previously referred to as a Health Maintenance Organization (HMO)?

A: It is recommended you obtain eligibility and benefit information prior to rendering services to patients. Click here for ways to verify eligibility. You can also do the following:

• Ask patients if they have recently enrolled in any new health insurance plans.
• Request to see a copy of all of their health insurance cards.

objective measures - What does it mean

Generally speaking, when we say 'objective measures,' what does that mean?

Answer: 

Objective measures consist of standardized patient assessment instruments, outcome measurements tools or measurable assessments of functional outcome. Use of objective measures at the beginning of treatment, during and/or after treatment is recommended to quantify progress and support justifications for continued treatment.

Reminder: Some forms, including the Oswestry, may not contain answers/responses that are objective (actual measures/values). The Chiropractor or patient may need to add additional information. For example, the form may use the term 'severe' for the evaluation of pain. 'Severe' is not an objective measure. The pain would need an specific value.

Examples of objective measures to evaluate goals include:

Pain
Baseline: 9 on a scale of 1-10
Goal: Decrease pain to 1
Standing:
Baseline: Only able to stand for 20 minutes
Goal: Able to stand for more than 1 hour
Range of Motion (ROM):
Baseline: Lumbar spine flexion of 53 degrees and extension 11 degrees
Goal: Increase lumbar flexion to 80 and extension to 25



Generally speaking, when we say a 'treatment plan with specific goals', what does that mean?

Answer:

Upon determination of a subluxation, the physician is required to develop an individualized treatment plan that includes the following:

Recommended level of care (duration and frequency of visits)
Specific treatment goals
Objective measures to evaluate treatment effectiveness
Objective measures consist of standardized patient assessment instruments, outcome measurements tools or measurable assessments of functional outcome. Use of objective measures at the beginning of treatment, during and/or after treatment is recommended to quantify progress and support justifications for continued treatment.

Some providers use forms (Oswestry, etc.) to measure treatment effectiveness. If this is the case, then a patient would need to complete the form on every visit.

Reminder: Some forms, including the Oswestry, may not contain answers/responses that are objective (actual measures/values). The Chiropractor or patient may need to add additional information. For example, the form may use the term 'severe' for the evaluation of pain. 'Severe' is not an objective measure. The pain would need a specific value.

Examples of objective measures to evaluate goals include:

Pain
Baseline: 9 on a scale of 1-10
Goal: Decrease pain to 1
Standing:
Baseline: Only able to stand for 20 minutes
Goal: Able to stand for more than 1 hour
Range of Motion (ROM):
Baseline: Lumbar spine flexion of 53 degrees and extension 11 degrees
Goal: Increase lumbar flexion to 80 and extension to 25


icd 10 code for allergic rhinitis - J30.1

Allergic rhinitis due to pollen 

J30.1 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes.
   
This is the American ICD-10-CM version of J30.1. Other international versions of ICD-10 J30.1 may differ.
   
Reimbursement claims with a date of service on or after October 1, 2015 require the use of ICD-10-CM codes.

Clinical Information

   
Allergic rhinitis caused by outdoor allergens.
   
Allergic rhinitis that occurs at the same time every year. It is characterized by acute conjunctivitis with lacrimation and itching, and regarded as an allergic condition triggered by specific allergens.
   
Each spring, summer, and fall, trees, weeds and grasses release tiny pollen grains into the air. Some of the pollen ends up in your nose and throat. This can trigger a type of allergy called hay fever.symptoms can include

        sneezing, often with a runny or clogged nose
        coughing and postnasal drip
        itching eyes, nose and throat
        dark circles under the eyes
        taking medicines, using nasal sprays and rinsing out your nose can relieve symptoms.

Allergy shots can help make you less sensitive to pollen and provide long-term relief. Seasonal variety of allergic rhinitis, marked by acute conjunctivitis with lacrimation and itching; regarded as an allergic condition triggered by specific allergens.

Applicable To

    Allergy NOS due to pollen
    Hay fever
    Pollinosis

Approximate Synonyms

Allergic rhinitis (nose congestion), pollen

The following ICD-10-CM Index entries contain back-references to ICD-10-CM J30.1:

    Allergy, allergic (reaction) (to) T78.40
    due to pollen J30.1
    grain J30.1
    grass (hay fever) (pollen) J30.1
    nasal, seasonal due to pollen J30.1
    pollen (any) (hay fever) J30.1
    primrose J30.1
    primula J30.1
    ragweed (hay fever) (pollen) J30.1
    rose (pollen) J30.1
    Senecio jacobae (pollen) J30.1
    tree (any) (hay fever) (pollen) J30.1
    inhalant (rhinitis) J30.89
    pollen J30.1


J30 Vasomotor and allergic rhinitis Includes: spasmodic rhinorrhea Excludes: allergic rhinitis with asthma (bronchial) (J45.909) rhinitis NOS (J31.0) J30.0 Vasomotor rhinitis J30.1 Allergic rhinitis due to pollen Allergy NOS due to pollen Hay fever Pollinosis

SJ30.2 Other seasonal allergic rhinitis

SJ30.5 Allergic rhinitis due to food

SJ30.8 Other allergic rhinitis

SJ30.81 Allergic rhinitis due to animal (cat) (dog) hair and dander

SJ30.89 Other allergic rhinitis

SPerennial allergic rhinitis

SJ30.9 Allergic rhinitis, unspecified

SJ31.0 Chronic rhinitis

SAtrophic rhinitis (chronic)

SGranulomatous rhinitis (chronic)

SHypertrophic rhinitis (chronic)

SObstructive rhinitis (chronic)

SOzena

SPurulent rhinitis (chronic)

SRhinitis (chronic) NOS

SUlcerative rhinitis (chronic)

SExcludes1: allergic rhinitis (J30.1-J30.9)

Svasomotor rhinitis (J30.0)

Includes: Allergic (predominantly) asthma Allergic bronchitis NOS Allergic rhinitis with asthma Atopic asthma Extrinsic allergic asthma Hay fever with asthma 
Idiosyncratic asthma Intrinsic nonallergic asthma Nonallergic asthma

SExcludes 1:

Sdetergent asthma (J69.8)

Seosinophilic asthma (J82)

Slung diseases due to external agents (J60-J70)

SMiner’s asthma (J60)

Swheezing NOS (R06.2) wood asthma (J67.8)

ICD- ALLERGIC DISORDERS

ICD-10CM

477.0

Allergic Rhinitis - pollen
J30.1

477.2

Allergic Rhinitis - danders
J30.81

477.8

Allergic Rhinitis - other
J30.89

477.1

Allergic Rhinitis - foods
J30.5

477.9

Allergic Rhinitis - unspecified
J30.9

372.05

Acute Atopic Conjunctivitis
H10.10- H10.13

372.00

Acute Conjunctivitis, unspecified eye
H10.30

Acute conjunctiviitis, unspecified rt eye
H10.31

Acute conjunctivitis, unspecified, left eye
H10.32

Acute conjunctivitis, unspecified, bilateral
H10.33

372.01

Acute Serous Conjunct-non viral
H10.231 thru H10.233

372.14

Chronic Allergic Conjunctivitis
H10.45

372.13

Seasonal conjunctivitis-childhood
H10.44

Simple chronic conjunctititis - right eye
H10.421

Simple chronic conjunctivitis - left eye
H10.422

Simple chronic conjunctivitis - bilateral
H10.423

Simple chronic conjunctivitis - unspecified eye
H10.429

381.04

OM acute allergic (mucoid) rt ear
H65.111

OM allergic acute & subacute lt ear
H65.112

OM allergic acute & subacute bilateral
H65.113

OM allergic recurrent rt ear
H65.114

OM allergic recurrent lt ear
H65.115

OM allergic recurrent bilateral
H65.116

OM allergic recurrent unspecified
H65.117

OM allergic and subacute unspecified
H65.119

381.1

OM Serous chronic, unspecified ear
H65.20

OM serous chronic, right ear
H65.21

OM Serous chronic, left ear
H65.22

OM Serous chronic, bilateral
H65.23

ICD-9CM

Skin Disorders

ICD-10CM

691.8

Atopic( neurodermatitis) Dermatitis
L20.81

Perioral Dermatitis
L71.0

692.84

Allergic eczema
L20.84

Contact , allergic due to adhesives
L23.1

692.8

Contact, allergic Dermatitis - animal
L23.81

692.0

Contact, allergy due to cosmetics
L23.2

692.3

Contact, allergy due to detergent
L23.89

692.5

Contact, allergy due to drugs (topical)
L23.3

692.4

Contact, allergy due to food
L23.6

692.83

Contact, allergy due to latex, rubber
L23.5

692.6

Contact, allergy due to metals
L23.0

Contact, allergy Due to plants
L23.7

Unspecified contact dermatitis, cosmetics
L25.0

Unspecified contact dermatitis, drugs
L25.1

Unspecified contact dermatitis, dyes
L25.2

Unspec contact dermatitis -other chemicals (cement, insecticide)
L25.3

Unspec contact dermatis food in contact
L25.4

Unspecified contact dermatitis due to plants
L25.5


For the practice of Allergy/Immunology, the conversion from ICD-9-CM to ICD-10-CM will be rather seamless for some diagnoses, and more complicated for others.

Asthma will be coded as intermittent or persistent, and add descriptors:

• Mild
• Moderate
• Severe

A fifth digit will be used to describe asthma as:
• Uncomplicated (x = 1)
• With exacerbation (x = 2)
• With status (x = 3).

FOOD PROTEIN0INDUCED ENTEROCOLITIS SYNDROME

K52.21 is a new, approved ICD-10 code for Food Protein-Induced Enterocolitis Syndrome FPIES is a non-IgE gastrointestinal food hypersensitivity that manifests as delayed, profuse vomiting, often with diarrhea, acute dehydration, and lethargy.

The most common triggers are milk and soy, but any food, even those thought to be hypoallergenic (e.g., rice and oat), can cause an FPIES reaction.

The new code is the result of advocacy efforts by the International Association for Food Protein Enterocolitis, a lay organization and partner of the AAAAI.

REPORTING DISEASES OF THE RESPIRATORY SYSTEM (J00-J99)

For the Respiratory disease, Chapter 10, the ICD-10 chapter instructions include the direction to use additional codes for describing the patient’s tobacco use, if documented in the patient’s medical record.

If the patient does not have a tobacco use, abuse, or dependence, no additional codes are required to describe your patient’s disease. For the patient who does use tobacco products and it is documented in their medical record, we must code not only their use but also describe the type of tobacco used.

The provider is directed to use only one code to describe the patient’s tobacco use. For example, if the patient uses and is dependent, you only assign the code for the dependence.

The provider must also select a sixth digit to describe if the patient’s dependence is as follows:

• 0 Uncomplicated
• 1 In remission
• 3 With withdrawal
• 8 With other nicotine-induced disorders
• 9 With unspecified nicotine-induced disorders

RESPIRATORY SYSTEM SCENARIOS

A patient presents with mild intermittent asthma who has smoked cigarettes in the past, but is not a current smoker. Your diagnosis codes would be J45.20 and Z87.891.

A patient presents with severe persistent asthma who is currently a long-time dependent cigarette smoker. Your diagnosis code would be J45.50 with F17.210.

A patient presents with moderate persistent asthma with no history of smoking or any use of tobacco products. Your correct diagnosis code(s) would be J45.40.

RHINITIS CODES

ICD-10 CM defines vasomotor rhinitis as a form of non-allergic rhinitis that is characterized by nasal congestion and posterior pharyngeal drainage.

J31.0 Chronic Rhinitis NOS description symptoms include:

• Rhinitis 
• Rhinitis (nasal congestion)
• Rhinitis (nasal congestion), chronic
• Rhinitis (nasal congestion), nonallergic
• Rhinitis due to alpha blocking medication
• Rhinitis due to alpha-adrenergic blocking agent
• Rhinitis medicamentosa

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