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.
In this article:
- Category of code for payers that don’t recognize consult codes
- Definition of a consultation
- 2021 documentation changes
- Crosswalk information
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 (99281—99285).
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,
- An opinion is provided, and
- A report is returned.
If billing consults, review the information in the CPT book about consults and transfers of care. It starts with the definition.
“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.
A physician consultant may initiate diagnostic and/or therapeutic services at the same or subsequent visit.”
2021 documentation changes complicate reporting consults
- 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.
Crosswalk based on MDM for inpatient consults
Based on the three key components, it is still possible to automatically crosswalk 99253—99255 exactly to 99221—99223. If the service is billed as 99251 or 99252, crosswalk it to a subsequent visit code 99231—99233. Since the requirements are slightly different (all three key components required for consults, and two of three required for a subsequent visit), the crosswalk isn’t automatic.
Crosswalk based on MDM for outpatient consults
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.
Crosswalk based on time
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.For more information on office consults and Medicare consult codes, or to determine proper usage of CPT® codes 99241-99245, become a member of CodingIntel today.