First, CMS stopped recognizing consult codes in 2010. Outpatient consultations (99241—99245) and inpatient consultations (99251—99255) were still active CPT^® codes, and depending on where you are in the country, are recognized by a payer two, or many payers.

• In 2023, codes 99241 and 99251 are deleted. These two low level consult codes were rarely used. There are four levels of office/outpatient consults and hospital consults. These correspond to the four levels of medical decision making.
• CPT has removed the coding tip –and all language– regarding transfer of care.
• CMS is not planning on changing its policy on consultations.

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.”

In this article about consultation codes update:

• Category of code for payers that don’t recognize consult codes
• Workflow
• Definition of a consultation–updated with 2023 CPT guidance
• 2023 documentation changes

See E/M changes for 2021 for additional E/M related resources.

Category of code for Medicare and other payers that don’t recognize consult codes

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 (99282—99285).

Workflow

How will clinicians know if the payer recognizes consults? They won’t know. Most groups suggest that their clinicians continue to select and document consults (when the service is a consult) whether or not they know if the payer recognizes consults or not. They set up an edit in their system so that consult codes can be reviewed and cross walked to the appropriate code, depending on the payer.

Definition of a consultation

When reporting a consultation code follow CPT rules. The statement that I recommend is “I am seeing this patient at the request of Dr. Patel for my evaluation of new onset a-fib.”  At the end of the note, indicate that a copy of the report is being returned to the requesting clinician. In a shared medical record, this can be done electronically.

The requirements for a consultation have not changed.

• There is a request from another healthcare professional or other appropriate source
• An opinion is provided, and
• A report is returned.

From 2023 CPT: “A consultation is a type of evaluation and management service provided at the request of another physician, other qualified health care professional, or appropriate source to recommend care for a specific condition or problem.

A physician or other qualified health care professional consultant may initiate diagnostic and/or therapeutic services at the same or subsequent visit.”

CPT goes on to say that if the consultation is initiated by a patient or family member or other appropriate source, do not use consult codes.  The list of professionals who are “other appropriate sources” according to CPT includes non-clinical social workers, educators, lawyers or insurance companies. However, if your payer still recognizes consults, they will likely require the NPI of a requesting clinician. You likely will not get paid for a consult requested by one of these professionals.

A report is required. “The consultant’s opinion and any other services that were ordered or performed must also be communicated by written report to the requesting physician, other qualified health care professional, or other appropriate source.”

• CPT does not say how the written report is returned: mail, fax, electronic communication.

When you look in your book, notice that CPT has entirely removed the concept of transfer of care. There is no longer a notation that says you cannot bill a consult for a transfer of care.

Consults in 2023 use medical decision making or time

• The AMA has extended the framework for office and outpatient services to consults in 2023. Use either medical decision making or the practitioner’s total time on the date of the visit to select the level of service.

Consulting physician services for hospitalized Medicare patients

Question:

What should a consulting physician bill when seeing a hospitalized Medicare patient? An initial hospital service or a subsequent hospital visit?

Answer:

Medicare stopped recognizing and paying consult codes, but consults are still requested and provided to inpatients every day. The question is, how should they be billed?

If the documentation supports an initial hospital service, use codes 99221-99223, initial hospital care codes.  According to CPT^®, these codes are used for new or established patients. While we think of them and even talk about them as “admission” codes, CPT^® doesn’t use that word.

If the documentation doesn’t have a detailed history and detailed exam, then bill a subsequent hospital visit, rather than the initial hospital care services. But, the correct category of code is initial hospital care. The citation from the Medicare Claims Processing Manual is at the end of this Q&A.

Many commercial insurance companies still recognize consults. Neglecting to bill consults when the carrier pays them results in lost revenue.

Citation from CMS | Inpatient Hospital Services

The CMS Claims Processing Manual, Chapter 12, §30.6.9 F

Physicians may bill initial hospital care service codes (99221-99223), for services that were reported with CPT^® consultation codes (99241 – 99255) prior to January 1, 2010, when the furnished service and documentation meet the minimum key component work and/or medical necessity requirements.

Physicians may report a subsequent hospital care CPT^® code for services that were reported as CPT^® consultation codes (99241 – 99255) prior to January 1, 2010, where the medical record appropriately demonstrates that the work and medical necessity requirements are met for reporting a subsequent hospital care code (under the level selected), even though the reported code is for the provider’s first E/M service to the inpatient during the hospital stay.

In the inpatient hospital setting and the nursing facility setting, physicians (and qualified nonphysician practitioners where permitted) may bill the most appropriate initial hospital care code (99221-99223), subsequent hospital care code (99231 and 99232), initial nursing facility care code (99304-99306), or subsequent nursing facility care code (99307-99310) that reflects the services the physician or practitioner furnished.

Subsequent hospital care codes could potentially meet the component work and medical necessity requirements to be reported for an E/M service that could be described by CPT^® consultation code 99251 or 99252. A/B MACs (B) shall not find fault in cases where the medical record appropriately demonstrates that the work and medical necessity requirements are met for reporting a subsequent hospital care code (under the level selected), even though the reported code is for the provider’s first E/M service to the inpatient during the hospital stay.

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