Consultation services

January 29th, 2009 - Codapedia Editor
Categories:   Coding   Evaluation & Management (E/M)  
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Let’s start with Medicare’s definition of a consultation

Medicare Claims Processing Manual, Publication 100-04, Chapter 12, Section 30.6.10A

Carriers pay for a reasonable and medically necessary consultation service when all of the following criteria for the use of a consultation code are met:


·      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.  Applicable collaboration and general supervision rules apply as well as billing rules;


·      A request for a consultation from an appropriate source and the need for consultation (i.e., the reason for a consultation service) shall be documented by the consultant in the patient’s medical record and included in the requesting physician or qualified NPP’s  plan of care in the patient’s medical record; and After the consultation is provided, the consultant shall prepare a written report of his/her findings and recommendations, which shall be provided to the referring physician.


The intent of a consultation service is that a physician or qualified NPP or other appropriate source is asking another physician or qualified NPP for advice, opinion, a recommendation, suggestion, direction, or counsel, etc. in evaluating or treating a patient because that individual has expertise in a specific medical area beyond the requesting professional’s knowledge.


Consultations may be billed based on time if the counseling/coordination of care constitutes more than 50 percent of the face-to-face encounter between the physician or qualified NPP and the patient.  The preceding requirements (request, evaluation (or counseling/coordination) and written report) shall also be met when the consultation is based on time for counseling/coordination.  


A consultation shall not be performed as a split/shared E/M visit.

What does a consult require? 

R’s it would seem!
 A consult requires a request from another healthcare professional, a reason for the consultation, an opinion is rendered and a report is returned. 
Let's start with the request.

The request should be documented in both the requesting and the consulting
clinician’s chart. 

Who may request a consult?

According to Medicare, a physician or a Non-Physician Practitioner (NPP) such as a Nurse Practitioner (NP) or Physician Assistant (PA) or other healthcare professional with an NPI number may request a consult. 

CPT® allows the requesting clinician to be "another appropriate source.” Could that be a lawyer or a school nurse?  It may be from a CPT® perspective, but what will you use on the CMS 1,500 form in a referring clinician box?

In practice, the request for a consult is limited to someone with a provider number.


What does the request in the requesting clinician’s medical record look like?


·      It may be a letter from the requesting clinician (that’s rare)

·      It could be an order in an inpatient chart “consult vascular surgery”

·      It often is part of the plan in an office visit such as “I suggested to her that she needs to see a surgeon for her ongoing abdominal complaints.”


Does the consulting physician need to receive something in writing from the requesting physician? 


No.  The rules say that the request needs to be documented in both the requesting and the consulting provider’s medical record.  But, there is not a requirement for a letter or a form.  Some practices require a faxed form or a letter out of compliance concerns.



Document the reasons.
Here are some examples:

"For my medical evaluation prior to her gallbladder surgery.” 

"For my opinion about her long standing bloating and diarrhea.”

"For an assessment of recently discovered breast lump.”

"In consultation for her recent diagnosis of cancer.”

RACE to use these words!

·      Request: “I am seeing this patient at the request of Dr. Ronald for my opinion…”

·      Advice:  “Patient sent by Dr. Hoff for my advice about…”

·      Consult: “Patient seen in consultation at the request of Dr. Kane”

·      Evaluation: “Dear Jim, thanks for asking me to evaluate Betsy for…”


The report must be returned from the consultant to the requesting clinician.

 This may be in the form of a letter to the requesting physician.  It could be a copy of the note if there is evidence that it was returned.

"A copy of this report is being returned to Ms. Hinkle, PA-C". 

In an inpatient note, the consultation dictation in the chart serves as the returned report.

In an electronic medical record, the report in the EMR serves as the report.  The EMR should keep a record of the report being returned to the requesting provider electronically.

In a group chart, the report in that chart serves as the returned report.


Document the request for the consult, the reason, and the fact that a report is returned to the requesting clinician.

Consultations are like beauty: too often in the eye of the beholder 

Example one:“I am seeing the patient at the request of Dr. Abbott for my assessment (or in consultation, or for my evaluation) of the patient's XYZ problem.” 
Example two:
 “Dear Dr. Referring,
 Thank you for asking me to assess (consult, evaluate, give my opinion) the patient's XYZ problem.”
What do you think of example three: Many would not call it a consult!
 “Dear John,
 I had the pleasure of seeing Betsy today for her new onset XYZ.  I found ABC. 
 Thank you for the opportunity to participate in the care of this patient.”
 Just say no to pleasure and participation! Be clear!  Most auditors would not call example 3 a consult

Second opinions—are they consults? New patient visits? Established patient visits? There are no longer any confirmatory consultation codes in the CPT® book. Second opinions may be a consult IF the criteria of a consultation are met.

If the consult is requested by a patient or family it is not a consult, it is a new or established patient visit depending on the patient’s status.  If the patient is seen in a hospital and a consult is requested by a family member, it may only be billed as a subsequent hospital visit if you are not the admitting physician.  Patients cannot request a consult. 
 Be cautious about the category of code.
 Follow-up services are billed with subsequent hospital visit in the 99231 to 99233 series of codes when provided in the hospital. In the nursing home, they are billed with subsequent nursing home visits in the 99307 to the 99310 series of codes.   In the office, follow up services are billed using established patient visit codes, in the 99212 to 99215 series of codes.

Be careful about consultations within the group.  Here is what the Medicare manual says about that:

Consultations Requested by Members of Same Group

Carriers pay for a consultation if one physician or qualified NPP in a group practice requests a consultation from another physician in the same group practice when the consulting physician or qualified NPP has expertise in a specific medical area beyond the requesting professional’s knowledge.  A consultation service shall not be reported on every patient as a routine practice between physicians and qualified NPPs within a group practice setting.

Consults in a group are allowed as long as the criteria of a consult are met.  However, get the patient to the right specialist in your group from the start.
Be cautious about billing consultations within a group. If the criteria for a consult are not met, it is a new or established patient visit within the group.  
The real difficulty about consultations is with transfer of care.
From the Medicare Claims Processing Manual:

A transfer of care occurs when a physician or qualified NPP requests that another physician or qualified NPP take over the responsibility for managing the patients’ complete care for the condition and does not expect to continue treating or caring for the patient for that condition.


When this transfer is arranged, the requesting physician or qualified NPP is not asking for an opinion or advice to personally treat this patient and is not expecting to continue treating the patient for the condition. The receiving physician or qualified NPP shall document this transfer of the patient’s care, to his/her service, in the patient’s medical record or plan of care.


In a transfer of care the receiving physician or qualified NPP would report the appropriate new or established patient visit code according to the place of service and level of service performed and shall not report a consultation service.

Examples of transfer of care:

·      Patient sent to your office from the ED

·      Patient sent from another hospital to tertiary care center

Clearly Consults
“Would you please evaluate this newly discovered breast lump?”
 “This is a patient with gallbladder disease.  Is she a surgical candidate at this time?”
Totally Transfers

1.    A patient is seen in the ED with abdominal pain and bulging.  The ED doctor calls you, but you do not feel you need to see the patient that night.  Patient presents to your office the next day.


2.    A surgeon in your practice sees a patient who will require laproscopic surgery.  You are most experienced at the procedure in question.  Your partner talks to you about the patient and you agree that is appropriate and accept the care of the patient. Your partner arranges for the patient to see you, and does not intend to continue treating the patient.



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