Over this past year, there have been significant changes to the consultation coding section of the Current Procedural Terminology (CPT) book from the American Medical Association (AMA). The major CPT changes were the deletion of the follow-up inpatient consultation codes 99261-99263 and confirmatory consultation codes 99271-99275.

These changes came about after the Office of Inspector General reported that errors in upcoding and lack of documentation in consultation services cost Medicare $1.1 billion. The Inspector General also reported that, based on the review of random selected consultation services for 2005, 45 percent of consultation services were not coded at the appropriate level. Accordingly, these changes in the consultation codes should significantly reduce incorrect coding errors.

A consultation is defined by the AMA as “a type of service provided by a physician whose opinion or advice regarding evaluation or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source.” Specifically, a consultation service is distinguished from other evaluation and management services because it is provided by a physician or qualified non-physician practitioner (NPP), whose opinion or advice is requested by another physician or clinician. A qualified NPP may perform consultation services within his or her scope of practice and licensure requirements in the state in which he or she practices. Applicable collaboration and general supervision rules of a physician will still apply as will billing rules for NPPs.

When coding and billing for consultations, keep in mind that what really distinguishes a consult from another E/M service are the three Rs. Namely, there is a request for an opinion or advice, a service is rendered and the professional reports back in writing to the requesting physician or non-physician practitioner what he or she did.



A consultation service requires a request from an appropriate source and can be written or verbal. Always verify that the request you receive from a physician is for a consultation and not just a referral for insurance purposes. Often, third-party payers may require the member to have a referral for all specialists from their primary care physician first. The primary care physician usually acts as the gatekeeper for the patient’s care.
If this is the case for the referral, this is not a request from the physician for a consultation. You should verify that the consultation is not at the patient’s request but has actually been requested by the physician who seeks your expertise for the patient’s given medical condition. A request initiated by a patient and/or family — and not by a physician or qualified NPP — cannot be reported as a consultation as it is considered an office visit.

Not only should you document the consultation visit but you should send a copy of your findings to the requesting physician so he or she can add it to the patient’s medical file. If the decision is made that you will take over the patient’s care, you should bill for the consultation. However, you must still send the written report to the requesting physician. When it comes to providing care after that, one should code this as an established outpatient visit in the office and as a subsequent hospital care service if it is in an inpatient setting.

Also keep in mind that if you receive an additional consultation request from the referring physician for an opinion or advice regarding the same problem or a new problem the patient is having, one may use the consultation codes again for both inpatient and outpatient services.

Pertinent Pointers On Outpatient Consultations
One would use the evaluation and management series codes 99241-99245 to report consultation services provided in a physician’s office or any other outpatient setting. Consultation services are required to meet the key components for billing an E/M service. Make sure there is proper documentation, especially for all high-level consults. When qualified non-physician practitioners are billing consultation services in an outpatient or inpatient setting for a new or established patient, all three key components of an E/M service are needed for billing.

Antanya A. Chung, CPC

Keep in mind that a comprehensive history and examination along with high complexity medical decision-making are required for all level five visits. Indeed, one should obtain an extended history of the present illness, a review of systems directly related to the presenting problem and a complete past, family and social history.

Inpatient Consultations: What You Should Know
When it comes to a second opinion consultation request through the attending physician in a facility setting, one should report this with the appropriate initial inpatient consultation CPT codes 99251-99255 when the consultation requirements are met. If you provide any follow-up care for the patient while he or she is still an inpatient, be sure to use the subsequent hospital care codes 99231-99233 to report these services.

In regard to consultations in inpatient settings, one should not bill these as shared visits. Non-physician practitioners should be careful when participating in consultation services with their physician. If you perform a consultation, you should bill under your non-physician practitioner’s number.

Physicians and qualified non-physician practitioners should also be aware of some of the following policy clarifications when billing for consultations.

• One may initiate diagnostic and/or therapeutic services at the initial consultation service or follow-up visits, and can bill these services with the E/M visit.
• One cannot bill a consultation as a share/split E/M visit.
• Clinicians must report ongoing management following the initial consultation service with the subsequent visit codes depending on the setting and type of service.
• In regard to consultation codes billed to Medicare and third-party payers, one must provide the referring physician’s name and Unique Physician/ Practitioner Identification Number (UPIN) and/or National Provider Identification (NPI).

Other Pertinent Documentation Pearls
Physicians and qualified non-physician practitioners should also be aware of the following pointers.

• Medicare does not recognize CPT codes 99211 for consultation visits. The level of service for these codes does not meet the consultation criteria.
• Physicians and non-physician practitioners should include a written request for a consultation in the requesting physician’s or NPP’s plan of care.
• The reason for the consultation must be documented by the consultant in the patient’s medical record.
• An initial inpatient consultation will be reported only once per patient per facility admission.
• If the consultant continues care for the patient for the original condition following the initial consultation, repeat consultation codes cannot be reported by the physician or qualified NPP during the management of the condition.
• A written report is not required by Medicare to be sent to the physician or qualified NPP when a second opinion evaluation has been requested by the patient and/or family.

Final Notes
Here are some final tips to keep in mind when documenting consultation services.

Don’t forget that even if there is nothing in the past, family and social history (PFSH) that is contributing to the pertinent presenting problem, you can receive credit for reviewing that information with the patient. If there is nothing significant, use this language in the medical records: “Past, family and social history reviewed and otherwise non-contributory.”

Melesia R. Collins, CPC

Practitioners should have some sort of cue card to remind them to check family history, especially when it comes to evaluating elderly patients. Without a record of family history, it is impossible to code your service above a level three.

Documentation is the key to billing for consultation services. Physicians and qualified non-physician practitioners must take the time to substantiate the services rendered. Your documentation is the story that you tell of what goes on in the examination room. Be careful not to use the terms “unremarkable” or “not relevant” for areas such as the review of systems and past, family and social history as these expressions set off red flags that you skipped these areas. Be as thorough as possible and follow the rules closely. Be aware of the old adage: “If it was not documented, it was not done.”