INPATIENT CONSULTATIONS

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REIMBURSEMENT POLICY

INPATIENT CONSULTATIONS

The services described in Oxford policies are subject to the terms, conditions and limitations of the Member's contract or certificate. Unless otherwise stated, Oxford policies do not apply to Medicare Advantage

enrollees. Oxford reserves the right, in its sole discretion, to modify policies as necessary without prior written notice unless otherwise required by Oxford's administrative procedures or applicable state law. The term Oxford includes Oxford Health Plans, LLC and all of its subsidiaries as appropriate for these policies. Certain policies may not be applicable to Self-Funded Members and certain insured products. Refer to the Member's plan of benefits or Certificate of Coverage to determine whether coverage is provided or if there are any exclusions or benefit limitations applicable to any of these policies. If there is a difference between any policy and the Member’s plan of benefits or Certificate of Coverage, the plan of benefits or Certificate of Coverage will govern.

APPLICABLE LINES OF BUSINESS/PRODUCTS

This policy applies to Oxford Commercial plan membership. APPLICATION

This policy applies to all network and non-network physicians and other qualified health care professionals, including but not limited to, non-network authorized and percent-of-charge contract physicians and other qualified health care professionals

OVERVIEW

A consultation is a type of service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source. The Same Individual Physician or Health Care Professional should submit only one initial inpatient consultation per admission.

For the purpose of this policy, the Same Individual Physician or Health Care Professional is the same individual rendering health care services reporting the same Federal Tax Identification number.

Policy Number: ADMINISTRATIVE 228.7 T0 Effective Date: February 1, 2015

Table of Contents

APPLICABLE LINES OF BUSINESS/PRODUCTS…...

APPLICATION………...

OVERVIEW...

REIMBURSEMENT GUIDELINES...

RESOURCES/REFERENCES...

POLICY HISTORY/REVISION INFORMATION...

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or appropriate source to either recommend care for a specific condition or problem or to

determine whether to accept responsibility for ongoing management of the patient's entire care or for the care of a specific condition or problem. Consultations provided to hospital inpatients and residents of nursing facilities may be reported using CPT codes 99251-99255. Only one inpatient consultation should be reported by a consultant per admission. Oxford will reimburse only one inpatient consultation per facility admission for the same patient when submitted by the Same Physician or Other Health Care Professional with CPT codes 99251-99255.

Follow-Up Consultation Services

If subsequent to the completion of a consultation the consultant assumes responsibility for management of a portion or all of the patient’s condition(s), the appropriate Evaluation and Management services codes for the site of service should be reported.

In the hospital setting following the initial inpatient consultation service, Subsequent Hospital Care codes CPT 99231-99233 should be reported for additional follow-up visits, which include services to complete the initial consultation, monitor progress, revise recommendations, or address a new problem.

In the nursing facility setting, following the initial inpatient consultation service, Subsequent Nursing Facility (NF) Care codes, CPT 99307-99310 should be reported for additional follow-up visits, which include services to complete the initial consultation, monitor progress, revise recommendations, or address a new problem.

Initial Inpatient Telehealth Consultation Services

Physician consultations delivered via telehealth to the emergency department or hospital inpatients and residents of nursing facilities should be reported using HCPCS codes G0425-G0427. Only one inpatient consultation should be reported by a consultant per encounter or admission for the same patient.

Follow-Up Telehealth Consultation Services

In the inpatient setting following the initial inpatient telehealth consultation service, Follow-up Inpatient Telehealth Consultation codes G0406-G0408 should be reported for additional follow-up visits, which include services to complete the initial telehealth consultation, monitor progress, revise recommendations, or address a new problem.

Coding

The codes listed in this policy are for reference purposes only. Listing of a service or device code in this policy does not imply that the service described by this code is a covered or non-covered health service. Coverage is determined by the Member's plan of benefits or Certificate of Coverage. This list of codes may not be all inclusive.

Inpatient Consultation Codes

CPT Code Description

99251

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CPT Code Description

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 physicians, other qualified health care professionals, 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. Physicians typically spend 40 minutes 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 physicians, other qualified health care professionals, 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. Physicians typically spend 55 minutes 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 physicians, other qualified health care professionals, 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. Physicians typically spend 80 minutes at the bedside and on the patient's hospital floor or unit.

99255

Inpatient consultation for a new or established patient, which requires 3 three key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, 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. Physicians typically spend 110 minutes at the bedside and on the patient's hospital floor or unit.

CPT® is a registered trademark of the American Medical Association. Subsequent Hospital Care Codes

CPT Code Description

99231

Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: a problem focused interval history; a problem focused examination; medical decision making that is

straightforward or of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is stable, recovering or improving. Physicians typically spend 15 minutes at the bedside and on the patient's hospital floor or unit.

99232

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CPT Code Description

99233

Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: a detailed interval history; a detailed examination; medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care

professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Physicians typically spend 35 minutes at the bedside and on the patient's hospital floor or unit. Subsequent Nursing Facility Care Codes

CPT Code Description

99307

Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: a problem-focused interval history; a problem-focused examination; straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is stable, recovering, or improving. Physicians typically spend 10 minutes at the bedside and on the patient's facility floor or unit.

99308

Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: an expanded problem-focused interval history; an expanded problem-problem-focused examination; medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Physicians typically spend 15 minutes at the bedside and on the patient's facility floor or unit.

99309

Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: a detailed interval history; a detailed examination; medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient has developed a significant complication or a significant new problem. Physicians typically spend 25 minutes at the bedside and on the patient's facility floor or unit.

99310

Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: a comprehensive interval history; a comprehensive examination; medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. The patient may be unstable or may have developed a significant new problem requiring immediate physician attention. Physicians typically spend 35 minutes at the bedside and on the patient's facility floor or unit.

Initial Inpatient Telehealth Consultation Codes HCPCS

Code Description

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G0427 Telehealth consultation, emergency department or initial inpatient, typically 70 minutes communicating with the patient via telehealth

Follow-Up Inpatient Telehealth Consultation Codes HCPCS

Code Description

G0406 Follow-up inpatient consultation, limited, physicians typically spend 15 minutes communicating with the patient via telehealth

G0407 Follow-up inpatient consultation, intermediate, physicians typically spend 25 minutes communicating with the patient via telehealth

G0408 Follow-up inpatient consultation, complex, physicians typically spend 35 minutes communicating with the patient via telehealth

RESOURCES/REFERENCES

The foregoing Oxford policy has been adapted from an existing UnitedHealthcare national policy that was researched, developed and approved by the UnitedHealthcare National Reimbursement Forum. [2014R0036A]

1. American Medical Association. Current Procedural Terminology (CPT®) and associated publications and services.

2. Centers for Medicare and Medicaid Services, CMS Manual System and other CMS publications and services.

POLICY HISTORY/REVISION INFORMATION

Date Action/Description

02/01/2015

• Updated policy overview language; replaced reference to “physicians and other healthcare professionals“ with “physicians and other qualified healthcare professionals”

• Updated policy application language; replaced reference to “same physician” with “same individual physician or health care

professional” • Removed definitions

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References

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