Consultations: When is a consult a consult?

Cracking the Code

Alexander Miller

Dr. Miller, who is in private practice in Yorba Linda, California, represents the American Academy of Dermatology on the AMA-CPT Advisory Committee.

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Your office receptionist greets you in the morning with a sticker note glued to your desk. You have a hospital patient consultation waiting for you. After collecting yourself you make time to visit and evaluate the patient. You render your opinion and give your recommendations. The physician requesting your input expects a consultation opinion, the hospital staff refers to you as a consultant, and the narrative document that you produce is called a consultation. You prepare a charge for your consulting services and then stop: do you bill for an inpatient consultation (99251-99255) or for a new hospital patient visit (99221-99223)? A similar question arises when you see patients referred for a consultation in your office/clinic (99241-99245 for consultation versus 99201-99205 for new patient visit).

How you should bill for consultations is directed by two essential factors: first, whether the criteria for a consultation were met, and second, whether the entity adjudicating your charges recognizes consultation codes and pays for them.

The 2013 Current Procedural Terminology (CPT) manual defines a consultation as “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.” The request for a consultation must come from an “appropriate source” in written or verbal form that should be documented in the patient’s record. Some insurers may require that the individual requesting the consultation also document the consultation request in their patient record. The “appropriate source” is defined in the CPT manual as a physician, physician assistant, nurse practitioner, chiropractor, physical therapist, occupational therapist, speech-language pathologist, psychologist, social worker, lawyer, or insurance company. Finally, the consultation itself should be documented in the patient’s record and a written report should be generated to the requesting individual or entity. [pagebreak]

Once all of the requirements for a consultation have been met it is time to decide whether the patient’s third-party payer recognizes the consultation CPT codes and will pay for them. Most private insurers will pay for consultations and will follow published CPT consultation guidelines. However, individual insurer policies vary and may change over time. Consequently, it is best to regularly examine relevant individual insurer contractual language, manuals, and policies. Insurers send explanations of benefits to your office and/or may provide online payment data. You, the billing physician, will benefit from a reliable review mechanism established in your office that will give you feedback on payments for each service billed. That will inform you whether the insurer is following its own policies and how much your charges are actually worth. If your bill is rejected as non-payable, and you do not know about it, your billing patterns may not change, and you will continue to provide services for which you do not receive payment.

There is one insurer that will not pay for any consultation codes at all. The Centers for Medicare and Medicaid Services (CMS) eliminated the use of all inpatient and office/outpatient consultation codes in 2010. This decision may be viewed in the following CMS transmittal: Consultations billed to Medicare are submitted as appropriate levels of new or established patient hospital, nursing home, or office visit Evaluation and Management (E/M) codes. [pagebreak]

If the patient for whom a consultation has been done requires subsequent care by you, the consultant, appropriate subsequent hospital care, nursing facility care, or office visit E/M codes should be used to reflect your level of service. In the hospital setting, only one consultation may be billed per patient during the course of the patient’s admission. For example, if you do an inpatient consultation, do not see the patient again, and then 10 days later are called to “reconsult” on the patient, the second visit is billed as a subsequent hospital care visit (99231-99233).

Example 1

A patient is referred to your clinic by the patient’s health insurer for a second opinion concerning diagnostic and therapeutic recommendations. Do you bill for a consultation or for a new patient office visit?

You bill an appropriate consultation code (99241-99245) and append modifier 32 indicating that the consultation was mandated by the third-party payer. (Check with your carrier; many do not use this modifier.) [pagebreak]

Example 2

You do an inpatient hospital consultation for a privately insured patient and bill an inpatient consultation code for your services. Two days later, due to a change in the patient’s status, you are requested to return to the hospital to re-evaluate the patient. You see the patient and then consider: should you bill for a new consultation?

The CPT definition explicitly states that only one consultation may be reported by the consultant during the course of a patient’s hospital or nursing facility admission. Thus, a subsequent evaluation is reported as a subsequent hospital care (99231-99233) or in the case of a nursing home admission, as subsequent nursing facility care (99307-99310).

Example 3

A patient with a written consultation request from her primary care physician is evaluated by you for a complex autoimmune condition. You do a comprehensive evaluation of the patient, including a detailed history and examination, and transmit a written report to the referring physician. The private insurer is billed a level 3 (99243) consultation code for your services. Alas, it turns out that the patient has just signed on with Medicare and your bill was rejected as a non-covered service (remark code MA130). What do you do?

The service should be rebilled to the patient’s Medicare contractor as a new patient encounter with an appropriate level 3 (CPT 99203) new patient evaluation visit code. No telephone call or redetermination form is required. Simpler coding mistakes such as those that involve the lack of or improper use of modifiers can be corrected via a telephone call to your Medicare contractor. Your contractor website offers a telephone number to call as well as a list of criteria that qualify for telephone claim correction.