Consultation Codes Update (2022)

Consultation Codes Update, June 2022: The May 2022 CPT Assistant announced there are changes coming to E/M codes in 2023, including consultations. The AMA plans to post these changes on their website in July, 2022.

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. However, in 2021 and 2022 not only are the time thresholds different for consult codes, consult codes use the 1995 and 1997 guidelines and office visits use the new E/M guidelines. This adds to confusion for what needs to be documented to meet the level of service. One colleague said, “This may be the final nail in the coffin for consult codes.” I wish it weren’t so, but it may be. Of course, when the AMA releases the consultation code update for 2023 (along with other E/M updates), we’ll know more.

In this article:

  • Category of code for payers that don’t recognize consult codes
  • Workflow
  • 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.

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For patients seen in the emergency department and sent home, use ED codes (99281—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,
  • 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.

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?

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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.

FAQs

What are the 3 key components used to determine a consultation visit? ›

What are the 3 key components used to determine a consultation visit?

What is a consultation code? ›

What is a consultation code?

How do you code consultation? ›

How do you code consultation?

Is there a CPT code for consultation? ›

Is there a CPT code for consultation?

What are the 3 R's for consultations? ›

What are the 3 R's for consultations?

What is a Level 3 consultation? ›

What is a Level 3 consultation?

What insurances dont accept consult codes? ›

What insurances dont accept consult codes?

How often are CPT codes updated? ›

How often are CPT codes updated?

Does Medicare pay for consultation codes? ›

Does Medicare pay for consultation codes?

What is the code for a consult Level 1? ›

What is the code for a consult Level 1?

Can consultations be split shared? ›

Can consultations be split shared?

Is 99214 a consult code? ›

Is 99214 a consult code?

What is the difference between 99446 and 99451? ›

What is the difference between 99446 and 99451?

What is the CPT code for new patient consultation? ›

What is the CPT code for new patient consultation?

When can you bill a consult code? ›

When can you bill a consult code?

What is the CPT code for initial consultation? ›

What is the CPT code for initial consultation?

Does Cigna pay for consult codes? ›

Does Cigna pay for consult codes?

What is a category code? ›

What is a category code?

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