Health Insurance Companies Process 1 in 5 Claims Wrong.

Consultation Codes: A Quick Reminder on How to Bill

medicare-consultation-codesA consultation, as defined by the CPT manual, is an 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.

When to Bill for a Consultation

  • Consultations can only be billed out when requested by another physician or appropriate source.
  • A consultation requested by a patient is not reported by using consultation codes; rather, it is reported by using the appropriate E/M code.  A patient requesting a second opinion or a consultation does not meet the CPT definition of a consultation code.

Documentation Requirements

  • Documentation of the written or verbal request for the consult from the requesting physician must be in the patient’s medical record and provided on the encounter form.  The requesting physician’s name must be referenced on the CMS 1500 claim form.
  • The consultant’s opinion and any services that were ordered or performed must also be documented in the patient’s medical record and must be communicated by a written report to the requesting physician or other appropriate source and recorded in the chart note.

Selecting the Appropriate Consultation Code

  • In the hospital or nursing facility setting, the consulting physician should use the appropriate inpatient consultation code for the initial encounter, and then hospital or nursing facility care codes for the subsequent encounter(s).
  • In the office setting, the physician should use the appropriate office or other outpatient consultation codes.

Consultations for Established Patients

A consultation code may be billed out for an established patient as long as the criteria for a consultation code are met.  There must be a notation in the patient’s medical record that consultation was requested and a notation in the patient’s medical record that a written report was sent to the requesting physician.

Do not use Consultation Codes for Medicare Patients

As Medicare no longer accepts consultation codes (effective January 1, 2010), the appropriate E/M code should be used for patients who have Medicare as their primary insurance.  Note that there are specific coding requirements for patients who have Medicare as secondary insurance coverage, which we will handle accordingly.

To watch a video on billing consultation codes to Medicare

If the criteria for a consultation code is not met, do not bill a consultation code. Instead, select the appropriate E/M.


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8 thoughts on “Consultation Codes: A Quick Reminder on How to Bill”

  1. blank

    I am a patient a saw my pcp on 8/12/21 for last appt because I relocated to SC. Through mychart I place a request for refill of Alendronate. On 8/19/21 my pcp called me, reported after being on the meds for over 10 years;which by the way well exceeded guidelines, she consulted endocrine. They decided I should take a medication holiday and redo bone density in 2 years. Then she called me, an unscheduled video/telephonic call, to explain all the above. I was proactive, scheduled my new pcp in SC, and lastly on the call I asked if she can write all she told me in mychart so I can share with new SC pcp. In October, there was a professional charge for my pcp $285 and another provider I never spoke or met with charging too $285. That’s $570 for two providers to discuss my medication holiday. That’s unethical because my pcp call me to discuss why she was not going to prescribe the meds, “she” spoke to a provider for her own clarity, I never set foot in the clinic, I had no appt scheduled so why the insurance have to pay for an interdisciplinary conversation between 2 providers? Had my pcp ordered a consult and “I” had an appt with endocrine, then of course Bill my insurance and charge me my copay! But a discussion between to providers with no consult, no appt, no patient just seem unethical! Thank you

  2. blank

    I work for a behavioral health facility and sometimes our physicians will ask for a second opinion on one of our psych patients. Can you tell me the correct CPT code to use for billing? when a second opinion is requested on a patient, the doc always writes an order and it is placed in the medical record for that patient.



  3. blank

    My obgyn doc was called into the ER to do a consult on a pt…the er doc coded the er consult…what code do I use for my doc??

  4. blank

    Great post. I really appreciate the insight here in this post and confident it’s going to be helpful to me and many others. Thanks for sharing your knowledge. Good work, keep it up.

  5. blank

    I was called on to do a medical consult on patient in a Rehab facility.
    What is the initial procedure code and the subsequent follow up codes?

    1. blank

      It really depends on the type of rehab facility. CMS recognizes several place of service designations for rehab. The codes will vary depending on the type of rehab facility in which you provided services. Can you please provide us with more information?

      CMS recognizes the following:

      Comprehensive Inpatient Rehabilitation Facility and Comprehensive Outpatient Rehabilitation Facility. There are also specific facilities for residential and non-residential substance abuse treatment facilities.

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