The primary team & the consult bill

As a consultant you are paid the same way every physician is paid for inpatient work: Part B professional dollars on the Physician Fee Schedule (total RVU × $33.40 × local GPCI). You do not touch the facility DRG — that is the hospital's Part A payment for the whole stay, shared across everyone who cares for the patient. The wrinkle that defines consult billing is that someone else is already billing an E/M on this patient every day.

The consultant reports the same hospital E/M codes as everyone else — initial hospital/inpatient care 99221–99223 on the day you first see the patient, then subsequent hospital care 99231–99233 on follow-up days. (The 2023 E/M revision merged inpatient and observation into this one family and moved leveling to MDM or total time.)

Two teams, two bills, same day — when does Medicare pay both?

• Different specialty (or different group) → both are paid. Pulmonary consulting on a patient admitted to hospital medicine, a surgical service, or cardiology is a different specialty designation in PECOS, so your E/M and the primary team's E/M on the same calendar day are each payable.
• Same specialty + same group → only one E/M. If the “primary” team is also PCCM in your own group, Medicare treats you as one physician for that patient that day — coordinate who bills rather than submitting two E/Ms.
• Two different specialties each bill their own E/M with no special modifier for the overlap — -25 is an intra-provider modifier (a procedure on the same day as your own E/M), not the mechanism for two physicians to coexist.

Commercial & Medicaid aside — consult codes may still live. Medicare doesn't recognize consultation codes, but many commercial and some Medicaid payers still accept inpatient consult codes 99252–99255 (99251 was deleted in 2023). They require the classic “3 R's”: a Request from another provider, the service you Render, and a written Report back to the requester. Check each payer before using them.

Common questions

Hospital E/M the consultant bills — 99221–99233

Your first day on a patient is initial hospital/inpatient care (99221–99223); every day after is subsequent hospital care (99231–99233). Since 2023 both are leveled by medical decision making (MDM) or total time on the date of the encounter — whichever is more favorable.

Initial & subsequent inpatient E/M

Work RVUs are national CY2026 values; dollars are approximate national (total facility RVU × $33.40, rounded) — verify against the CMS PFS Look-Up Tool. Local GPCI varies.

Leveling by MDM — pulmonary consult examples

Pick MDM or time, whichever favors the visit. Common consult-service MDM anchors:

• Moderate (99222 / 99232): COPD or asthma exacerbation, a new pleural effusion being worked up, a pulmonary nodule, starting or adjusting prescription drug therapy.
• High (99223 / 99233): acute respiratory failure, massive/submassive PE, massive hemoptysis, decompensation with a decision about escalation or transfer to the ICU — or drug therapy requiring intensive toxicity monitoring.

Past the top of the highest level, prolonged inpatient time adds on: CPT 99418 for most payers, but Medicare uses G0316 — don't report 99418 to Medicare.

Can a consult service bill critical care time? Yes — with conditions

Critical care (99291 first 30–74 min; 99292 each additional 30 min) is not reserved for the ICU team of record. A pulmonary consultant who personally delivers critical care can bill it — for example, directing management of acute respiratory failure on a ward patient or a surgical-service patient.

It is still time-based and definition-gated. Both must be true: (1) a critical illness/injury acutely impairing a vital organ system with a high probability of imminent, life-threatening deterioration, AND (2) high-complexity decision-making to treat or prevent it. A sick-but-stable consult is hospital E/M (99221–99233), not critical care. See the ICU page's critical-care section for the time→code mapping and the list of services bundled into 99291/99292.

The conditions that let a consultant bill it

• Different specialty/group from whoever else is billing critical care. Two physicians of the same specialty in the same group have their minutes aggregated into one 99291 claim — they can't each bill it. A different specialty does bill its own 99291 for its own critical-care work. (See the aggregation rules.)
• Your time must independently be critical care and directed at the failing organ system — not routine follow-up.
• No double-counting. Simultaneous bedside time with another physician is counted once; carve out any separately billable procedure minutes.

Watch the same-group trap: if your group is the ICU team of record, the minutes aggregate — you don't get a second 99291. The clean consultant critical-care bill is when you're a distinct specialty/group from the team already billing.

Working with a resident or APP on a consult

Whose work counts depends on whether you're with a resident/fellow (Teaching Physician rules) or an APP/NPP (split/shared rules). Don't conflate them. Pulmonary fellows are residents for Medicare teaching-physician purposes.

Residents & fellows — Teaching Physician (TP) rules

• The service bills under the teaching physician, who must personally see the patient and perform (or be present for) the portion that determines the level.
• Leveling by MDM: the TP may verify the resident's/fellow's documented history, exam, and assessment rather than re-document them, but must personally participate in the decision-making and say so.
• Leveling by time: only the TP's own time counts — resident-alone time does not.
• Critical care with a resident: only the TP's personal minutes count, and there is no split/shared with a resident — the service bills under the TP.
• Append modifier GC. The Primary Care Exception (GE) does not apply to inpatient consults or critical care.

APPs / NPPs — split (or shared) visit rules

• Applies when a physician and an APP (NP/PA) in the same group both personally perform part of the same patient's care on the same calendar day.
• Combine the physician's and APP's work/time; whoever performed the substantive portion bills (for time-based services, >50% of the combined time). Append modifier FS.
• Payment lever: APP-billed pays ~85% of the fee schedule; physician-billed (substantive portion) pays 100%.
• Document both individuals by name, each one's role/time, the combined total, and who did the substantive portion; the billing clinician signs and dates.

Quick decision guide

A procedure performed with a trainee also needs a supervision / teaching-physician presence statement in the procedure note. Medicare rules; split/shared substantive-portion definitions have shifted year to year — confirm current CMS/MAC policy.

Bedside procedures

Bronchoscopy is intentionally deferred to a separate page. This section covers the bedside procedures a pulmonary consult service commonly performs on the floor.

Most bedside procedures are separately payable in addition to the same-day E/M — but (1) append modifier -25 to the E/M so the payer doesn't bundle it into the procedure, and (2) carve the procedure minutes out of any critical-care time.

Imaging-guidance traps. (1) 32555/32557 already include imaging guidance — do not also bill needle-guidance 76942 with them. (2) A diagnostic pleural ultrasound you interpret is 76604; in a hospital that owns the machine, bill the professional component only with -26. Most of these procedures carry a 000-day global, so a same-day E/M with -25 is generally payable.

Necessary elements of a billable procedure note

• Indication / medical necessity — why now.
• Informed consent (or documented emergency exception).
• Time-out / patient ID for invasive procedures.
• Technique & site — approach, laterality, anesthesia/prep, image guidance (and whether guidance is bundled).
• Findings, specimens, devices placed (e.g., fluid volume removed, catheter type/size, post-procedure CXR for pneumothorax).
• Complications (or explicit “none”) and post-procedure status.
• Provider attestation + supervision/teaching-physician statement if a trainee assisted.
• Time statement confirming procedure time was excluded from critical-care minutes.

CY2026 Medicare PFS, national/unadjusted; thoracentesis, tube thoracostomy, intubation, and arterial-line dollars are total facility RVU × $33.40. Tunneled-catheter, pleurodesis, and removal values are setting-dependent — verify each against the CMS PFS Look-Up Tool and check NCCI edits for the specific pair.

Ventilator management — bill E/M (or critical care), not the vent codes

There are dedicated ventilator-management CPT codes — 94002 (first inpatient day), 94003 (subsequent inpatient days), 94004 (nursing facility) — but for an active consult service they're almost always the wrong choice.

The trap: 94002–94004 are bundled — they cannot be reported on the same day as critical care or a hospital E/M by the same physician for the same patient, and they pay little. Billing the vent code instead of your E/M forfeits the more valuable service.

So when you're consulted for ventilator management:

• Bill subsequent hospital care (99231–99233) leveled by MDM — ventilator dependence plus acute, chronic, or acute-on-chronic respiratory failure readily supports moderate-to-high decision-making — or
• Bill critical care (99291/99292) if the patient meets the critical-care definition and you personally provide the time.
• Don't report 94002–94004 alongside these — you'd give up the E/M.

Document the respiratory-failure type (acute / chronic / acute-on-chronic, hypoxemic vs hypercapnic), the ventilator settings and changes you directed, and the weaning plan — that's what supports the E/M level and the medical necessity of your daily involvement.

The narrow place 94002–94004 fit is a provider who is not also furnishing an E/M or critical care for that patient that day — rare for an active consult. When in doubt, the E/M (or critical care) is the service to document and bill.

Consult modifiers that matter

Sources & caveats

• Professional RVU/$ figures use CY2026 Medicare PFS values (conversion factor $33.40); national, unadjusted, and approximate. Confirm individual codes against the CMS PFS Look-Up Tool; inpatient services pay the facility rate.
• Inpatient/observation E/M leveling, MDM, and prolonged-service rules per the AMA CPT 2023+ framework and CMS (99418 vs Medicare G0316). Medicare does not recognize consultation codes — consultants report hospital E/M 99221–99223 / 99231–99233; the principal physician of record appends modifier AI. Many commercial/Medicaid payers still accept inpatient consult codes 99252–99255 (99251 deleted 2023) under the request/render/report requirements.
• Critical care (99291/99292) is time-based and definition-gated; a distinct-specialty consultant may bill it. Same-specialty/same-group physician minutes aggregate into one claim. Teaching-physician documentation per the Medicare Claims Processing Manual ch. 12 §100; split/shared substantive-portion definitions have shifted year to year.
• Ventilator-management codes 94002–94004 are bundled with same-day critical care/E/M by the same physician (CPT/NCCI) — bill the E/M or critical care instead.
• Procedure RVUs/payments (thoracentesis, pleural drainage/catheter, tube thoracostomy, pleurodesis, intubation, arterial line) per CY2026 Medicare PFS; image-guidance bundling and global periods per NCCI. Bronchoscopy is covered on a separate page.
• This is an educational documentation-improvement reference — not coding, legal, or financial advice, and not an official CMS, AMA, or MAC product. CPT® is a registered trademark of the AMA. Final code assignment rests with certified coders/CDI and your compliance team.

Built as a static reference site, companion to the Critical Care (ICU) and Pulmonary Clinic pages. Professional values current as of CY2026 Medicare rules. Re-verify at the next PFS / CPT update.