CPT® defines consultation as “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.” To substantiate a consultation service, documentation must include three elements: a request, a reason or render, and a report or reply referred to as the 3 R's of consultation coding.
It might appear that codes for consults and hospital visit codes are interchangeable. When patients are transferred into your care to continue medical treatment, for example, can you use a consultation code? After all, you’ve been brought into the case by another physician for your expertise in hospital medicine.
CMS stopped recognizing consult codes in 2010.
Outpatient consultations (99241—99245) and inpatient consultations (99251—99255) are still active CPT® codes, and depending on where you are in the country, are recognized by a payer two, or many payers.
The advantages to using the consult are codes are twofold: they are not defined as new or established and may be used for patients the clinician has seen before, if the requirements for a consult are met and they have higher RVUs and payments.
Take a careful look at Medicare’s documentation guidelines, and you’ll find that the answer is “no.” Routine transfer of care or referral is not considered part of the consultation service. It would be appropriate in these situations to refer to the initial hospital visit codes 99221-99223.
When CMS stopped paying for consults, it said it still recognized the concept of consults, but paid for them using different categories of codes. For an inpatient service, use the initial hospital services codes (99221—99223). If the documentation doesn’t support the lowest level initial hospital care code, use a subsequent hospital care code (99231—99233). Don’t make the mistake of always using subsequent care codes, even if the patient is known to the physician.
For office and outpatient services, use new and established patient visit codes (99202—99215), depending on whether the patient is new or established to the physician, following the CPT rule for new and established patient visits. Use these codes for consultations for patients in observation as well, because observation is an outpatient service.
For patients seen in the emergency department and sent home, use ED codes (99281—99285)
If moving from an outpatient consult to a new or established patient visit based on MDM, use only the level of MDM to select the new or established visit code. Consults still use the 1995/1997 guidelines, and office visits use the new 2021 guidelines for MDM. Missing in the new guidelines: the concept of new to the examiner, and new with work up planned. Added to the new guidelines: more credit for data analysis and the clarification that procedure risk is risk to the patient and/or risk inherent to the procedure. A practice will need to assess whether the levels would be the same in most cases in their specialty, or whether to send the claim to the clinician to code using the new guidelines or whether to have a coder code it using the new guidelines.
The time thresholds for each of these categories is different, so if the clinician uses time to select the consult codes, it will need to be reviewed and the correct code selected based on both time and the rules relating to time. Codes 99202—99215 can be selected based on total practitioner time on the date of the encounter. Outpatient consult codes can be based on face-to-face time, if more than 50% is spent in counseling and/or coordination of care. Inpatient services can be based on unit time, if more than 50% of the visit is based on counseling and/or coordination of care.
The Centers for Medicare and Medicaid Services (CMS) distinguishes consultation services from hospital visit codes, stating that consults are “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.” In other words, consults tend to be more focused on the opinion of colleagues and less on action or treatment.
In a simplistic view, payers expect consultation services to be part of a process that starts when a physician requests a consult, a physician renders a service, and the consultant returns to the initial physician to give a reply in the form of opinion or advice.
From this basic process comes the three “R’s” of consultation coding: request, render and reply.
Request
First, let’s review some basic criteria about requests for consults. The following items can help you make sure you’re meeting the criteria for a consult:
Here are the criteria for rendering care:
When consultants reply back to the referring physician, they must provide treatment recommendations or an opinion. In the inpatient setting, this is commonly done through the shared medical record of the hospital.
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It might appear that codes for consults and hospital visit codes are interchangeable. When patients are transferred into your care to continue medical treatment, for example, can you use a consultation code? After all, you’ve been brought into the case by another physician for your expertise in hospital medicine.
CMS stopped recognizing consult codes in 2010.
Outpatient consultations (99241—99245) and inpatient consultations (99251—99255) are still active CPT® codes, and depending on where you are in the country, are recognized by a payer two, or many payers.
The advantages to using the consult are codes are twofold: they are not defined as new or established and may be used for patients the clinician has seen before, if the requirements for a consult are met and they have higher RVUs and payments.
Take a careful look at Medicare’s documentation guidelines, and you’ll find that the answer is “no.” Routine transfer of care or referral is not considered part of the consultation service. It would be appropriate in these situations to refer to the initial hospital visit codes 99221-99223.
When CMS stopped paying for consults, it said it still recognized the concept of consults, but paid for them using different categories of codes. For an inpatient service, use the initial hospital services codes (99221—99223). If the documentation doesn’t support the lowest level initial hospital care code, use a subsequent hospital care code (99231—99233). Don’t make the mistake of always using subsequent care codes, even if the patient is known to the physician.
For office and outpatient services, use new and established patient visit codes (99202—99215), depending on whether the patient is new or established to the physician, following the CPT rule for new and established patient visits. Use these codes for consultations for patients in observation as well, because observation is an outpatient service.
For patients seen in the emergency department and sent home, use ED codes (99281—99285)
- If reporting a consultation (99241—99245, 99251—99255) to a payer that still recognizes consults, use the 1995/1997 guidelines to select a level of service.
- If reporting a hospital service (99221—99223, 99231—99233) use the 1995/1997 guidelines to select a level of service.
- If reporting a new or established patient service (99202—99215) use the new, 2021 E/M guidelines.
If moving from an outpatient consult to a new or established patient visit based on MDM, use only the level of MDM to select the new or established visit code. Consults still use the 1995/1997 guidelines, and office visits use the new 2021 guidelines for MDM. Missing in the new guidelines: the concept of new to the examiner, and new with work up planned. Added to the new guidelines: more credit for data analysis and the clarification that procedure risk is risk to the patient and/or risk inherent to the procedure. A practice will need to assess whether the levels would be the same in most cases in their specialty, or whether to send the claim to the clinician to code using the new guidelines or whether to have a coder code it using the new guidelines.
The time thresholds for each of these categories is different, so if the clinician uses time to select the consult codes, it will need to be reviewed and the correct code selected based on both time and the rules relating to time. Codes 99202—99215 can be selected based on total practitioner time on the date of the encounter. Outpatient consult codes can be based on face-to-face time, if more than 50% is spent in counseling and/or coordination of care. Inpatient services can be based on unit time, if more than 50% of the visit is based on counseling and/or coordination of care.
The Centers for Medicare and Medicaid Services (CMS) distinguishes consultation services from hospital visit codes, stating that consults are “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.” In other words, consults tend to be more focused on the opinion of colleagues and less on action or treatment.
In a simplistic view, payers expect consultation services to be part of a process that starts when a physician requests a consult, a physician renders a service, and the consultant returns to the initial physician to give a reply in the form of opinion or advice.
From this basic process comes the three “R’s” of consultation coding: request, render and reply.
Request
First, let’s review some basic criteria about requests for consults. The following items can help you make sure you’re meeting the criteria for a consult:
- Who is initiating or requesting the consultation? Your documentation needs to refer to a provider’s name (an individual physician, not a medical group) and a unique physician identification number (UPIN). Medicare will not pay a consult code without this information.
- A “consult” initiated by a patient, family member or third-party payer (in other words, a consult not requested by a physician) should not be billed using initial inpatient consultation codes. Medicare rules say this type of consult fits the definition of a confirmatory consult (CPT 99271-99275).
- Does the medical record document a written or verbal request for a consultation? According to Medicare guidelines, in an inpatient setting where the medical record is shared between the referring physician and the consultant, the request may be documented as part of a plan written in the requesting physician’s progress note, an order in the medical record or a specific request for consultation.
Here are the criteria for rendering care:
- The medical record needs to contain documentation of the consultant’s opinion, advice and (if applicable) any services that may have been ordered or performed. CPT guidelines state that a consultant can initiate diagnostic and/or therapeutic services to help formulate an opinion. CPT instructs that only one initial inpatient consultation should be billed per hospital admission.
- If the transfer of care will be given to the consultant to treat the problem after an opinion is rendered, each visit after the consult should be reported as a subsequent hospital visit (CPT 99231-99233). If not, care remains with the referring physician for treatment and follow-up.
- If the consultant can’t complete an opinion on the initial consult day, or if the referring physician requests the consultant to return later to provide additional advice, use follow-up inpatient consultation codes (99261-99263). You must thoroughly document additional consult days. Also make sure you describe modifications to management options or advise of a new plan for patient care.
When consultants reply back to the referring physician, they must provide treatment recommendations or an opinion. In the inpatient setting, this is commonly done through the shared medical record of the hospital.
The three "R's" of consultation codes: request, render and reply
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