January 28th, 2009 - Codapedia Editor
Categories:   Coding   Evaluation & Management (E/M)  
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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.   


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