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Consultation Codes: A Quick Reminder on How to Bill

Health Insurance Companies Process 1 in 5 Claims Wrong


A consultation, as defined by the CPT manual, is a 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 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 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 a 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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is a 20 year veteran of healthcare having managed medical practices. He advises medical practices, physicians and practice administrators on how to run their practice and manage their medical billing and revenue cycle management. Manny speaks, blogs and makes videos at www.CaptureBilling.com, a blog that is tops in the medical billing and coding field. READ MORE

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4 Responses to Consultation Codes: A Quick Reminder on How to Bill

  1. 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.

  2. 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?

    • 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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The analysis of any medical billing or coding question is dependent on numerous specific facts -- including the factual situations present related to the patients, the practice, the professionals and the medical services and advice. Additionally, laws and regulations and insurance and payer policies (as well as coding itself) are subject to change. The information that has been accurate previously can be particularly dependent on changes in time or circumstances. The information contained in this web site is intended as general information only. It is not intended to serve as medical, health, legal or financial advice or as a substitute for professional advice of a medical coding professional, healthcare consultant, physician or medical professional, legal counsel, accountant or financial advisor. If you have a question about a specific matter, you should contact a professional advisor directly. CPT copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

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