CPT Code 99252: Inpatient or Observation Consultations for a New or Established Patient

What is CPT code 99252?

CPT code 99252 describes an evaluation and management consultation service provided by a physician or another qualified health care professional to a new or established patient in an inpatient or observation setting. This code is typically used when another provider formally requests an evaluation or specialist advice regarding a patient admitted to the hospital or placed under observation care services. The consultation generally involves straightforward medical decision-making or at least 35 minutes of total provider time spent on the date of the encounter.

Providers utilize CPT consultation codes like 99252 specifically when the situation does not require the higher-level complexity defined by codes like 99253–99255, which require a detailed or comprehensive history. This code explicitly applies to inpatient or observation settings and not for home or residence services or care in an office or outpatient setting.

What is a level 2 inpatient consultation?

A level 2 inpatient consultation is an evaluation and management service performed at a straightforward level of complexity. It includes taking an expanded problem focused history and medically appropriate examination. The primary purpose is to provide advice or recommendations for minor or less severe patient issues. This consultation level suits clinical scenarios where the patient's condition does not demand the intensity of a comprehensive history or extensive evaluation seen in higher consultation codes.

CPT code 99252 documentation requirements

Accurate documentation for CPT 99252 must explicitly include the following components:

Referring provider’s documented request

Clearly record the name of the referring provider and explicitly note their request for the consultation.

Reason for consultation and clinical question

Document a specific clinical issue or question prompting the consult, such as a minor symptom or straightforward diagnostic query.

Medically appropriate expanded problem-focused history and exam

Include documentation of an expanded problem-focused history relevant to the patient’s presenting issue, as well as an appropriate examination.

Review of tests, labs, and imaging

Include a brief review of pertinent diagnostic data, if applicable.

Assessment and recommendations

Clearly state your clinical assessment, findings, and any management advice provided.

Total time documentation

Document total consultation time if billing based on time, confirming at least 35 minutes.

Report to referring physician

A formal written report summarizing findings and recommendations must be communicated back to the referring provider.

CPT code 99252 billing guidelines

Key billing considerations for CPT 99252 include:

Formal request required

You can only bill 99252 when the consultation is explicitly requested by another provider. It cannot be used for routine inpatient visits or transfers of care initiated by the admitting physician.

Appropriate use of total time

The consultation is typically billed based on a total time of 35–44 minutes. Total time includes reviewing records, patient assessment, documentation, and provider communication.

Not billable concurrently with hospital care codes

Do not report this code with other initial hospital inpatient E/M codes (99221–99223) on the same service date.

Verify payer acceptance

Confirm payer policies regarding acceptance of consultation codes, as some payers, notably Medicare, do not reimburse inpatient consult codes separately.

Medical necessity

Ensure all documentation supports payer-specific medical necessity requirements for inpatient consultation billing.

Applicable modifiers for CPT code 99252

The following modifiers may be appropriately appended to CPT 99252, depending on circumstances:

• Modifier GC: Service performed by a resident under a teaching physician's supervision.
• Modifier 24: Unrelated E/M service during a postoperative period.
• Modifier 25: Significant, separately identifiable E/M service on the same day of a procedure.
• Modifier 57: Decision for surgery.
• Modifier 22: Increased procedural services (substantially greater than typical work).
• Modifier 95 or GQ: Telehealth service, when applicable and allowed by the payer.

These modifiers clarify specific contexts or billing scenarios for accurate reimbursement.

Other relevant CPT codes

Here are related CPT consultation codes:

• 99253–99255 – Higher-level inpatient consultations requiring moderate to high complexity.
• 99221–99223 – Initial hospital care codes, typically used by the admitting physician for inpatient admissions.
• 99218–99220 – Hospital outpatient observation services, for observation status patients not formally admitted as inpatients.
• 99341, 99342, 99344, 99345 – Home or residence services, used for patient encounters conducted in home settings, contrasting with inpatient consultations.