Are You a Consultant?


I recently received the following question: "A local neurologist had a patient with headaches and history of meningitis. He referred the patient over for an evaluation to rule out papilledema. What (CPT) code should I use for that?"

This clinical/billing situation comes down to a few considerations, many we have discussed extensively in prior blog posts. What most of us will do is use the codes we use for most other clinical situations, ophthalmological codes or E&M codes.

Using one of the above codes is not incorrect, but there is a set of codes that were created for this circumstance, they are called Consultation Codes.

What are consultation codes?

Consultation codes were designed to recognize the complexity and communication that is involved in the above clinical situation. According to CPT a consultation is an E&M service provided at the request of another physician or appropriate source to:

  • 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

Why would we use consultation codes?

Simply put, these codes justify a higher reimbursement due to the following:

  • There is added complexity when one physician needs the opinion of another physician the condition is already more involved - getting worse or beyond the scope of the original physician.

  • There is added work and coordination when we are in communication with another physician.

When can we use consultation codes?

Consultation codes should be billed when the evaluation was requested by another physician. The patient can't be self-referred for an initial symptom or for a second opinion, unless that second opinion was requested by another physician. The patient must be referred for the consultation by another physician with communication from the referring provider (in this case the neurologist) to the accepting provider (in this case the OD).

What are the documentation requirements?

Consultations can be billed for both new and established patients as long as:

  1. Document a written or verbal request (I like written if possible) for the consult from the requesting physician in the chart.

  2. Requesting physician’s name must be referenced on the claim form.

  3. Your opinion and any services that were ordered or performed must also be documented in the patient’s medical record (as you would do for any encounter) but you also must communicate findings to the requesting PCP in a written report and that should additionally be noted in the chart.

How do we know what level of consultation we performed?

We follow the same for determining consultation codes as we would follow for other 99 codes:

Consultation E&M Equivalent

99241 99201

99242 99202

99243 99203

99244 99204

99245 99205

As an example, if we qualified for a 99204 based on history, examination and MDM, we would also qualify for a 99244 if we have the appropriate request for consult and communication back to the requesting physician documented in the chart.

Can we bill Consultations to Medicare?

No, in 2010 Medicare made the determination that they would no longer accept consultation codes, the appropriate E&M codes should be billed instead.

Find more billing and coding education here.

Have a great week! - Chris