Consultations

January 28th, 2009 - Codapedia Editor

Categories: Coding Evaluation & Management (E/M)

CPT® defines two sets of consultation codes: outpatient/office consults using 99241 through 99245 and inpatient/nursing facility consults using codes 99251 through 99255.

The Center for Medicaid and Medicare Services (CMS) defines a consult in this way

Specifically, a consultation service is distinguished from other evaluation and

management (E/M) visits because it is provided by a physician or qualified

nonphysician practitioner (NPP) whose opinion or advice regarding evaluation

and/or management of a specific problem is requested by another physician or

other appropriate source. The qualified NPP may perform consultation services

within the scope of practice and licensure requirements for NPPs in the State in

which he/she practices.

The citation goes on to say that the request for the consultation and the specific reason for the consult, shall be documented in both the requesting and the consulting clinician's note. And finally, after the consultation is finished, a copy of the report is returned to the requesting clinician.

This is where we get the four Rs of consultation. It requires a request from another healthcare professional, and that request should be documented in both the requesting and the consulting clinician's note. It requires a specific, medically necessary reason. After the physician has rendered the opinion, then a copy of the report is returned to the requesting clinician. So, we often say you need R’s for a consultation.

Remember: it's only a consult if you say it's a consult and the criteria of the consultation are met. The CMS definition states that the intent of the consultation is asking the other physician or qualified NPP for “advice, opinion, a recommendation, suggestion, direction, or counsel, et cetera, in evaluating or treating a patient, because that individual has expertise in a specific medical area beyond the requesting professional's knowledge.”

The manual continues that you may bill a consultation based on time if the criteria for billing based on time are met. In order to bill an E/M service based on time, counseling must dominate the visit. Document the total time of the office visit, the fact that more than 50% of the visit was spent in that discussion and the nature of the discussion. (See also billing services based on time in Codapedia.)

Be careful about the semantics of consultation. “I had the pleasure of seeing your patient today in my office,” and, “Thank you for allowing me to participate in the care,” do not document a request for opinion.

Use words that are defined in the CMS manual to describe a consultation: request, assessment, consultation, evaluation, opinion, rather than words like referral, pleasure and participation, which don't indicate as explicitly that there was a consult.

###

Questions, comments?

If you have questions or comments about this article please contact us. Comments that provide additional related information may be added here by our Editors.

Latest articles: (any category)

Artificial Intelligence in Healthcare - A Medical Coder's Perspective
December 26th, 2023 - Aimee Wilcox

We constantly hear how AI is creeping into every aspect of healthcare but what does that mean for medical coders and how can we better understand the language used in the codeset? Will AI take my place or will I learn with it and become an integral part of the process that uses AI to enhance my abilities?

Specialization: Your Advantage as a Medical Coding Contractor
December 22nd, 2023 - Find-A-Code

Medical coding contractors offer a valuable service to healthcare providers who would rather outsource coding and billing rather than handling things in-house. Some contractors are better than others, but there is one thing they all have in common: the need to present some sort of value proposition in order to land new clients. As a contractor, your value proposition is the advantage you offer. And that advantage is specialization.

ICD-10-CM Coding of Chronic Obstructive Pulmonary Disease (COPD)
December 19th, 2023 - Aimee Wilcox

Chronic respiratory disease is on the top 10 chronic disease list published by the National Institutes of Health (NIH). Although it is a chronic condition, it may be stable for some time and then suddenly become exacerbated and even impacted by another acute respiratory illness, such as bronchitis, RSV, or COVID-19. Understanding the nuances associated with the condition and how to properly assign ICD-10-CM codes is beneficial.

Changes to COVID-19 Vaccines Strike Again
December 12th, 2023 - Aimee Wilcox

According to the FDA, CDC, and other alphabet soup entities, the old COVID-19 vaccines are no longer able to treat the variants experienced today so new vaccines have been given the emergency use authorization to take the place of the old vaccines. No sooner was the updated 2024 CPT codebook published when 50 of the codes in it were deleted, some of which were being newly added for 2024.

Updated ICD-10-CM Codes for Appendicitis
November 14th, 2023 - Aimee Wilcox

With approximately 250,000 cases of acute appendicitis diagnosed annually in the United States, coding updates were made to ensure high-specificity coding could be achieved when reporting these diagnoses. While appendicitis almost equally affects both men and women, the type of appendicitis varies, as dose the risk of infection, sepsis, and perforation.

COVID Vaccine Coding Changes as of November 1, 2023
October 26th, 2023 - Wyn Staheli

COVID vaccine changes due to the end of the PHE as of November 1, 2023 are addressed in this article.

Medicare Guidance Changes for E/M Services
October 11th, 2023 - Wyn Staheli

2023 brought quite a few changes to Evaluation and management (E/M) services. The significant revisions as noted in the CPT codebook were welcome changes to bring other E/M services more in line with the changes that took place with Office or Other Outpatient Services a few years ago. As part of CMS’ Medicare Learning Network, the “Evaluation and Management Services Guide” publication was finally updated as of August 2023 to include the changes that took place in 2023. If you take a look at the new publication (see references below),....