The Consultation Conundrum

Deborah Grider, CPC, CPC-P, CPC-I, COC, CPMA, CEMC, CCS-P, CDIP

Many practitioners have stopped billing consultations. Why is that? Even though consultation codes 99241-99245 (outpatient) and 99251-99255 (inpatient) are no longer reported or payable by Medicare, other payers still allow us to report consultations, including many Medicaid state agencies. Medicare stopped allowing consultation codes on January 1, 2010.¹ But United Healthcare has a new payment policy that allows payment for consultations.² Other payers, including Cigna, Aetna, and Anthem, do cover consultations in most states. However, many Medicare Advantage Plans follow Medicare guidelines, so it is advisable to check with each payer before reporting consultations ​and to keep a list of which payers accept consultation codes.

So what is truly a consultation? The Current Procedural Terminology (CPT) instructional notes state: “A consultation is a type of evaluation and management service provided at the request of another physician or appropriate source to either recommend care for a specific condition or problem or to determine whether to accept responsibility for ongoing management of the patient’s entire care or for the care of a specific condition or problem.”³

What is an appropriate source? According to the American Medical Association, appropriate sources for a consultation request includes physicians, physician assistants, nurse practitioners, psychologists, social workers, lawyers, or insurance companies.⁴

Inpatient Consultations
The inpatient consultation codes (99251-99255) apply to consultations performed in the hospital, partial hospital, or nursing facility settings. The outpatient consultation codes (99241-99245) are reported in the office, domiciliary, rest home, or home settings.

For an inpatient consultations (99251-99255), the following requirements must be met:

• The clinician’s opinion or advice is requested, usually by the admitting physician. The service is provided at the request of another physician (or other appropriate source) to either recommend care for a specific condition or problem or to determine whether to accept responsibility for ongoing management of the patient’s entire care or for the care of a specific condition or problem.
• The request is documented in the patient’s medical record by either the consulting or requesting physician or other appropriate source.
• The physician may order diagnostic tests and/or therapeutic services at the same or subsequent visit, and the visit is still a consultation (assumes no transfer of care before the patient was evaluated).
• The consultant documents his/her opinion in the hospital medical record in addition to the documentation of any other services performed or ordered.
• An inpatient consultation is reported once per hospital admission.

For Medicare patients and payers who follow Medicare rules, the practitioner should report 99221-99223 for the initial inpatient visit or 99231-99233, depending on documentation. The practitioner should make certain that the documentation contains the required elements for reporting the consultation.

​Examples of Inpatient Consultations

• You are asked by Dr. Hospitalist to see a patient for possible pericardiocentesis.
• You are asked by Dr. Neurosurgeon to see a patient for possible tracheostomy because of the need for continued intubation after a stroke.​

Tables 1 illustrates the key component requirements, relative value units (RVUs) and typical times for reporting consultations, hospital care, and office or other outpatient services.^3,5



​For Medicare patients and other payers who do not accept consultation codes, the codes in Tables 2 and 3 should be reported for inpatients.





Outpatient Consultations
For an outpatient consultation, (99241-99245) the following requirements must be met:

• The service is provided at the request of another physician (or other appropriate source) to either recommend care for a specific condition or problem or to determine whether to accept responsibility for ongoing management of the patient’s entire care or for the care of a specific condition or problem.
• There is documentation of a written or verbal request for consultation by a physician or other appropriate source.
• The request is documented in the patient’s medical record by either the consulting or requesting physician or other appropriate source.
• The physician may order diagnostic tests and/or therapeutic services at the same or subsequent visit, and the visit is still a consultation (assumes no transfer of care before the patient was evaluated).
• The consultant documents his/her opinion in the medical record in addition to the documentation of any other services performed or ordered.
• The consultant sends a separate written report, personalized about the patient, to the requesting
• provider.
• Follow-up visits are reported using the appropriate codes for established patients (99211-99215).
• For an additional request for an opinion or advice regarding the same or new problem received from another physician or appropriate source and documented in the record, the office consultation codes may be used again.

Tables 5 and 6 illustrate new and established patient office visit codes that should be used for Medicare consultations and payers who follow Medicare guidelines.




Conclusion
As you can see in the tables, the RVUs and reimbursement may be higher for consultations. Know what guidelines your payers follow, and code based on their rules. If the payer allows a consultation and the criteria is met for a consultation, it is important to code and to be reimbursed for the service you provide. 

​References
1. Centers for Medicare & Medicaid Services. MLN Matters MM6740. Washington, DC: Centers for Medicare & Medicaid Services; 2009.
2. UnitedHealthcare Community Plan. Consultation Services Policy. Reimbursement Policy CMS-1500. Hot Springs AK: United Healthcare Community Plan; 2017. https://www.uhccommunityplan.com/content/dam/communityplan/healthcareprofessionals/reimbursementpolicies/Consultation_Services_Policy_(R0129).pdf​. Accessed July 28, 2017.
3. American Medical Association. Current Procedural Terminology. Professional Edition. Chicago, IL: American Medical Association; 2017.
4. American Medical Association. CPT Assistant. Chicago, IL: American Medical Association; 2014;24(9).
5. Centers for Medicare & Medicaid Services. Physician Fee Schedule. Washington, DC: Centers for Medicare & Medicaid Services;2017. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files-Items/RVU17A.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=descending. Accessed July 28, 2017.