A 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 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.