Kara Wong Ramsey, MD, Scott D. Duncan, MD, MHA

Current Procedural Terminology (CPT®) codes are updated annually; providers must be knowledgeable about changes that affect their billing practices. The American Medical Association (AMA) updated guidelines for CPT® Evaluation and Management (E/M) codes effective January 1, 2023, for both inpatient (99252-99255) and outpatient consultation (99242-99245) to decrease documentation burden irrelevant to patient care and reduce provider burn out. All observation hospital codes have been removed. Hospital visit codes for both inpatient and outpatient “observation status” will be merged and billed with inpatient codes (99221-99223; 99231-99233; 99234-99236). 

In addition, of particular interest to neonatologists, the level of service time has been adjusted for consultation codes, and level 1 outpatient and inpatient codes have been eliminated. Inpatient consultation codes (99252-99255) may be chosen based on medical decision-making (MDM) or time. A consultant may report only one consultation code during an admission. Subsequent consultations during the same hospital stay are reported using the subsequent hospital inpatient codes (99231-99233). Table 1 lists the CPT® code, level of MDM, and time component. Typically, prenatal consultations with hospitalized patients are time-based. It is no longer required to state that >50% of the time is spent on counseling and/or care coordination for consultation codes. 

Table 1 : Inpatient CPT® Consultation Codes 

CPT® code	MDM	Time
Initial consultation
99252	Straightforward	Meet or exceed 35 min
99253	Low	Meet or exceed 45 min
99254	Moderate	Meet or exceed 60 min
99255	High	Meet or exceed 80 min
Subsequent consultation
99231	Straightforward or Low	Meet or exceed 25 min
99232	Moderate	Meet or exceed 35 min
99233	High	Meet or exceed 50 min

Question: 

You are asked to see a new inpatient consult, referred by the maternal-fetal medicine doctor at 39 weeks gestation for maternal in-utero opioid exposure. The patient is a 30-year-old G1P0 whose pregnancy is notable for chronic use of oxycodone three times daily over the past year due to back pain after a motor vehicle accident. She is admitted for induction of labor at 39 weeks. The patient is concerned about a potentially prolonged hospital stay for neonatal opioid withdrawal syndrome, as mentioned by her maternal-fetal medicine doctor during a previous office visit. You spend 15 minutes reviewing her medical chart and prenatal records before seeing the patient. You spend 20 minutes in direct face-to-face contact with the patient explaining the need to observe her infant for at least 72 hours in the hospital per American Academy of Pediatrics recommendations to evaluate for neonatal opioid withdrawal syndrome. You discuss the possible need for NICU admission if the baby requires pharmacological treatment for severe symptoms and answer all her questions. You spend an additional 15 minutes explaining your recommendations to the obstetrical team, answering their questions about the safety of providing breastmilk to the infant if the mother remains on oxycodone, and documenting your recommendations in your consultation note. 

Which CPT code should you use? 

A. 99252 Straightforward complexity inpatient consult 35 minutes 

B. 99253 Low complexity inpatient consult 45 minutes 

C. 99254 Moderate complexity inpatient consult 60 minutes 

D. 99255 High complexity inpatient consult 80 minutes 

Answer: B 99253 Inpatient consultation, low complexity, 45 minutes 

When the CPT® code is chosen based on time, reporting the total of face-to-face and non-face-to-face time spent on the patient encounter on the same day is appropriate. Although you cannot include time spent by other clinical staff (such as RN or MA), you can report time that you personally spent preparing for the visit through chart review, face-to-face time with the patient, placing additional orders, interpreting lab or imaging results, care coordination, communicating with other health care team members and documenting in the medical record. However, note that the time spent on these non-face-to-face activities must be performed on the same day of the encounter to include the total sum of time. You cannot count time spent on the day prior to your patient encounter. 

This vignette presented an inpatient consultation with the proper CPT® code based on time spent (the sum of face-to-face and non to face to face time, including preparation work). For medical problems that may seem straightforward to an experienced neonatologist, the parents may spend a long time asking to clarify or follow-up questions or requesting other family members’ presence during the consultation. The prospect of potentially having a baby in the NICU is daunting, and we owe it to our families to spend the time necessary to answer their questions to the fullest extent possible. Conversely, some families may not spend much time asking questions. Perhaps the family is already familiar with the medical condition from previous experience or cannot receive much detailed medical information, in which case a follow-up consultation visit may be warranted. 

References: 

1. AMA CPT Evaluation and Management Code and Guideline Changes Available online at: https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf 
2. CPT® 2023: Professional Edition (2022). American Medical Association 

Biographical Sketch 

Dr. Duncan received his undergraduate degree from Transylvania University in Lexington, KY, and completed his medical training at the University of Louisville. He completed a Master’s Degree in Healthcare Administration at the Gillings School of Global Public Health at the University of North Carolina at Chapel Hill in 2011. He is currently the Chief of the Division of Neonatal Medicine at the University of Louisville. Dr. Duncan is a Fellow of the American Academy of Pediatrics and is the Chair of the Coding Committee of the Section on Neonatal-Perinatal Medicine, where he has been a member since 2010 Dr. Kara Wong Ramsey received her undergraduate degree from Stanford University in California and completed her medical training at Harvard Medical School in Boston, MA, and post-graduate medical training with Hawaii Residency Programs in Honolulu, HI. She is a neonatologist at Kapiolani Medical Center for Women and Children in Honolulu, HI. Dr. Wong Ramsey is a Fellow of the American Academy of Pediatrics and has been a member of the Coding Committee of the Section on Neonatal-Perinatal Medicine since 2020. 

Disclosure: The author has no disclosures.