Consultation Services
Medicare Claims Processing Manual
Chapter 12 – Physicians/Nonphysician Practitioners
30.6.10 – Consultation Services (Codes 99241-99255)
(Rev. 788, Issued: 12-20-05, Effective: 01-01-06, Implementation: 01-17-06)
A. Consultation Services versus Other Evaluation and Management (E/M) Visits
Carriers pay for a reasonable and medically necessary consultation service when all of the following criteria for the use of a consultation code are met:
- Specifically, a consultation service is distinguished from other evaluation and management (E/M) visits because it is provided by a physician or qualified nonphysician practitioner (NPP) whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source. The qualified NPP may perform consultation services within the scope of practice and licensure requirements for NPPs in the State in which he/she practices. Applicable collaboration and general supervision rules apply as well as billing rules;
- A request for a consultation from an appropriate source and the need for consultation (i.e., the reason for a consultation service) shall be documented by the consultant in the patient’s medical record and included in the requesting physician or qualified NPP’s plan of care in the patient’s medical record; and
- After the consultation is provided, the consultant shall prepare a written report of his/her findings and recommendations, which shall be provided to the referring physician.
The intent of a consultation service is that a physician or qualified NPP or other appropriate source is asking another physician or qualified NPP for advice, opinion, a recommendation, suggestion, direction, or counsel, etc. in evaluating or treating a patient because that individual has expertise in a specific medical area beyond the requesting professional’s knowledge. Consultations may be billed based on time if the counseling/coordination of care constitutes more than 50 percent of the face-to-face encounter between the physician or qualified NPP and the patient. The preceding requirements (request, evaluation (or counseling/coordination) and written report) shall also be met when the consultation is based on time for counseling/coordination.
A consultation shall not be performed as a split/shared E/M visit.
B. Consultation Followed by Treatment
A physician or qualified NPP consultant may initiate diagnostic services and treatment at the initial consultation service or subsequent visit. Ongoing management, following the initial consultation service by the consultant physician, shall not be reported with consultation service codes. These services shall be reported as subsequent visits for the appropriate place of service and level of service. Payment for a consultation service shall be made regardless of treatment initiation unless a transfer of care occurs.
Transfer of Care
A transfer of care occurs when a physician or qualified NPP requests that another physician or qualified NPP take over the responsibility for managing the patients’ complete care for the condition and does not expect to continue treating or caring for the patient for that condition.
When this transfer is arranged, the requesting physician or qualified NPP is not asking for an opinion or advice to personally treat this patient and is not expecting to continue treating the patient for the condition. The receiving physician or qualified NPP shall document this transfer of the patient’s care, to his/her service, in the patient’s medical record or plan of care. In a transfer of care the receiving physician or qualified NPP would report the appropriate new or established patient visit code according to the place of service and level of service performed and shall not report a consultation service.
C. Initial and Follow-Up Consultation Services
Initial Consultation Service
In the hospital setting, the consulting physician or qualified NPP shall use the appropriate Initial Inpatient Consultation codes (99251 – 99255) for the initial consultation service.
In the nursing facility setting, the consulting physician or qualified NPP shall use the appropriate Initial Inpatient Consultation codes (99251 – 99255) for the initial consultation service.
The Initial Inpatient Consultation may be reported only once per consultant per patient per facility admission.
In the office or other outpatient setting, the consulting physician or qualified NPP shall use the appropriate Office or Other Outpatient Consultation (new or established patient) codes (99241 – 99245) for the initial consultation service.
If an additional request for an opinion or advice, regarding the same or a new problem with the same patient, is received from the same or another physician or qualified NPP and documented in the medical record, the Office or Other Outpatient Consultation (new or established patient) codes (99241 – 99245) may be used again. However, if the consultant continues to care for the patient for the original condition following his/her initial consultation, repeat consultation services shall not be reported by this physician or qualified NPP during his/her ongoing management of this condition.
Follow-Up Consultation Service
Effective January 1, 2006, the follow-up inpatient consultation codes (99261 – 99263) are deleted.
In the hospital setting, following the initial consultation service, the Subsequent Hospital Care codes (99231 – 99233) shall be reported for additional follow-up visits.
In the nursing facility setting, following the initial consultation service, the Subsequent Nursing Facility (NF) Care codes (new CPT codes 99307 – 99310) shall be reported for additional follow-up visits. Effective January 1, 2006, CPT codes 99311 – 99313 are deleted and not valid for Subsequent NF visits.
In the office or other outpatient setting, following the initial consultation service, the Office or Other Outpatient Established Patient codes (99212 – 99215) shall be reported for additional follow-up visits. The CPT code 99211 shall not be reported as a consultation service. The CPT code 99211 is not included by Medicare for a consultation service since this service typically does not require the presence of a physician or qualified NPP and would not meet the consultation service criteria.
D. Second Opinion E/M Service Requests
Effective January 1, 2006, the Confirmatory Consultation codes (99271 – 99275) are deleted.
A second opinion E/M service is a request by the patient and/or family or mandated (e.g., by a third-party payer) and is not requested by a physician or qualified NPP. A consultation service requested by a physician, qualified NPP or other appropriate source that meets the requirements stated in Section A shall be reported using the initial consultation service codes as discussed in Section C. A written report is not required by Medicare to be sent to a physician when an evaluation for a second opinion has been requested by the patient and/or family.
A second opinion, for Medicare purposes, is generally performed as a request for a second or third opinion of a previously recommended medical treatment or surgical procedure. A second opinion E/M service initiated by a patient and/or family is not reported using the consultation codes.
In both the inpatient hospital setting and the NF setting, a request for a second opinion would be made through the attending physician or physician of record. If an initial consultation is requested of another physician or qualified NPP by the attending physician and meets the requirements for a consultation service (as identified in Section A) then the appropriate Initial Inpatient Consultation code shall be reported by the consultant. If the service does not meet the consultation requirements, then the E/M service shall be reported using the Subsequent Hospital Care codes (99231 – 99233) in the inpatient hospital setting and the Subsequent NF Care codes (99307 – 99310) in the NF setting.
A second opinion E/M service performed in the office or other outpatient setting shall be reported using the Office or Other Outpatient new patient codes (99201 – 99205) for a new patient and established patient codes (99212 – 99215) for an established patient, as appropriate. The 3 year rule regarding “new patient” status applies. Any medically necessary follow-up visits shall be reported using the appropriate subsequent visit/established patient E/M visit codes.
The CPT modifier -32 (Mandated Services) is not recognized as a payment modifier in Medicare. A second opinion evaluation service to satisfy a requirement for a third party payer is not a covered service in Medicare.
E. Consultations Requested by Members of Same Group
Carriers pay for a consultation if one physician or qualified NPP in a group practice requests a consultation from another physician in the same group practice when the consulting physician or qualified NPP has expertise in a specific medical area beyond the requesting professional’s knowledge. A consultation service shall not be reported on every patient as a routine practice between physicians and qualified NPPs within a group practice setting.
F. Documentation for Consultation Services
Consultation Request
A written request for a consultation from an appropriate source and the need for a consultation must be documented in the patient’s medical record. The initial request may be a verbal interaction between the requesting physician and the consulting physician; however, the verbal conversation shall be documented in the patient’s medical record, indicating a request for a consultation service was made by the requesting physician or qualified NPP.
The reason for the consultation service shall be documented by the consultant (physician or qualified NPP) in the patient’s medical record and included in the requesting physician or qualified NPP’s plan of care. The consultation service request may be written on a physician order form by the requestor in a shared medical record.
Consultation Report
A written report shall be furnished to the requesting physician or qualified NPP.
In an emergency department or an inpatient or outpatient setting in which the medical record is shared between the referring physician or qualified NPP and the consultant, the request may be documented as part of a plan written in the requesting physician or qualified NPP’s progress note, an order in the medical record, or a specific written request for the consultation. In these settings, the report may consist of an appropriate entry in the common medical record.
In an office setting, the documentation requirement may be met by a specific written request for the consultation from the requesting physician or qualified NPP or if the consultant’s records show a specific reference to the request. In this setting, the consultation report is a separate document communicated to the requesting physician or qualified NPP.
In a large group practice, e.g., an academic department or a large multi-specialty group, in which there is often a shared medical record, it is acceptable to include the consultant’s report in the medical record documentation and not require a separate letter from the consulting physician or qualified NPP to the requesting physician or qualified NPP. The written request and the consultation evaluation, findings and recommendations shall be available in the consultation report.
G. Consultation for Preoperative Clearance
Preoperative consultations are payable for new or established patients performed by any physician or qualified NPP at the request of a surgeon, as long as all of the requirements for performing and reporting the consultation codes are met and the service is medically necessary and not routine screening.
H. Postoperative Care by Physician Who Did Preoperative Clearance Consultation
If subsequent to the completion of a preoperative consultation in the office or hospital, the consultant assumes responsibility for the management of a portion or all of the patient’s condition(s) during the postoperative period, the consultation codes should not be used postoperatively. In the hospital setting, the physician or qualified NPP who has performed a preoperative consultation and assumes responsibility for the management of a portion or all of the patient’s condition(s) during the postoperative period should use the appropriate subsequent hospital care codes to bill for the concurrent care he or she is providing. In the office setting, the appropriate established patient visit codes should be used during the postoperative period.
A physician (primary care or specialist) or qualified NPP who performs a postoperative evaluation of a new or established patient at the request of the surgeon may bill the appropriate consultation code for evaluation and management services furnished during the postoperative period following surgery when all of the criteria for the use of the consultation codes are met and that same physician has not already performed a preoperative consultation.
I. Surgeon’s Request That Another Physician Participate In Postoperative Care
If the surgeon asks a physician or qualified NPP who had been treating the patient preoperatively or who had not seen the patient for a preoperative consultation to take responsibility for the management of an aspect of the patient’s condition during the postoperative period, the physician or qualified NPP may not bill a consultation because the surgeon is not asking the physician or qualified NPP’s opinion or advice for the surgeon’s use in treating the patient. The physician or qualified NPP’s services would constitute concurrent care and should be billed using the appropriate subsequent hospital care codes in the hospital inpatient setting, subsequent NF care codes in the SNF/NF setting or the appropriate office or other outpatient visit codes in the office or outpatient settings.
J. Examples That Meet the Criteria for Consultation Services
For brevity, the consultation request and the consultation written report is not repeated in each of these examples. Criteria for consultation services shall always include a request and a written report in the medical record as described above.
EXAMPLE 1:
An internist sees a patient that he has followed for 20 years for mild hypertension and diabetes mellitus. He identifies a questionable skin lesion and asks a dermatologist to evaluate the lesion. The dermatologist examines the patient and decides the lesion is probably malignant and needs to be removed. He removes the lesion which is determined to be an early melanoma. The dermatologist dictates and forwards a report to the internist regarding his evaluation and treatment of the patient. Modifier -25 shall be used with the consultation service code in addition to the procedure code. Modifier -25 is required to identify the consultation service as a significant, separately identifiable E/M service in addition to the procedure code reported for the incision/removal of lesion. The internist resumes care of the patient and continues surveillance of the skin on the advice of the dermatologist.
EXAMPLE 2:
A rural family practice physician examines a patient who has been under his care for 20 years and diagnoses a new onset of atrial fibrillation. The family practitioner sends the patient to a cardiologist at an urban cardiology center for advice on his care and management. The cardiologist examines the patient, suggests a cardiac catheterization and other diagnostic tests which he schedules and then sends a written report to the requesting physician. The cardiologist subsequently periodically sees the patient once a year as follow-up. Subsequent visits provided by the cardiologist should be billed as an established patient visit in the office or other outpatient setting, as appropriate. Following the advice and intervention by the cardiologist the family practice physician resumes the general medical care of the patient.
EXAMPLE 3:
A family practice physician examines a female patient who has been under his care for some time and diagnoses a breast mass. The family practitioner sends the patient to a general surgeon for advice and management of the mass and related patient care. The general surgeon examines the patient and recommends a breast biopsy, which he schedules, and then sends a written report to the requesting physician. The general surgeon subsequently performs a biopsy and then periodically sees the patient once a year as follow-up. Subsequent visits provided by the surgeon should be billed as an established patient visit in the office or other outpatient setting, as appropriate. Following the advice and intervention by the surgeon the family practice physician resumes the general medical care of the patient.
I. Examples That Do Not Meet the Criteria for Consultation Services
EXAMPLE 1: Standing orders in the medical record for consultations.
EXAMPLE 2: No order for a consultation.
EXAMPLE 3: No written report of a consultation.
EXAMPLE 4: The emergency room physician treats the patient for a sprained ankle. The patient is discharged and instructed to visit the orthopedic clinic for follow-up. The physician in the orthopedic clinic shall not report a consultation service because advice or opinion is not required by the emergency room physician. The orthopedic physician shall report the appropriate office or other outpatient visit code.
Revised November 3, 2011