How do I use consultation codes?
By Marty Kotlar, DC, CHCC, CBCS

I’ve heard of consultation codes, but I’m not sure how to use them. Are they used when I do consultation or does an MD have to refer the patient to me?

You can bill for consultation codes. Consultation codes require another healthcare provider to request your opinion or advice on the evaluation and management of the patient.

On the initial visit, you must perform a history, do an examination, make medical decisions, and then write and send a report to the referring healthcare professional, such as an MD, DO, another DC, nurse-practitioner, physical therapist, or psychologist.

On this visit, you may also want to initiate diagnostic and/or therapeutic services. Remember, however, that at this point you are co-treating the patient with the referring provider so you’ll want to document this patient encounter very well.

Important: If or when the referring provider transfers the responsibility for treatment to you at the time of the referral, you cannot bill a consultation visit. You would bill an appropriate established-patient code.

You may report a consultation if the referring physician does not transfer the responsibility for the patient’s care to you (the receiving physician) until after the consultation is completed.

Consultations requested by members within the same group are eligible for payment as long as all of the requirements for use of the consultation codes are met. But a consultation initiated by a patient and/or family member and not directly requested (in writing or verbally) from a healthcare professional, is reported using the office-visit codes, not the consultation codes.

The CPT codes for outpatient consultations are:

• 99241 — Office consultation for a new or established patient. Use this code when:

1. You take a problem-focused history;
2. You perform a problem-focused examination; and
3. Straightforward medical decision making results.

Counseling and/or coordination of care with other providers or agencies are provided, consistent with the nature of the problem(s) and the patient’s and/or family’s needs.

Usually, the presenting problem(s) is self limited or minor.

Physicians typically spend 15 minutes face-to-face with the patient and/or family.

• 99242 — Office consultation for a new or established patient. This code requires an expanded problem-focused history, expanded problem-focused exam, and straightforward medical decision making.

Counseling and/or coordination of care with other providers or agencies are provided, consistent with the nature of the problem(s) and the patient’s and/or family’s needs.

Usually, the presenting problem(s) is of low severity. Physicians typically spend 30 minutes face-to-face with the patient and/or family.

• 99243 — Office consultation for a new or established patient. This code requires a detailed history, detailed examination, and medical decision making of low complexity.

Usually, the presenting problem(s) is of moderate severity. Physicians typically spend 40 minutes face-to-face with the patient and/or family.

• 99244 — Office consultation for a new or established patient. This code requires a comprehensive history, comprehensive examination, and medical decision making of moderate complexity.

Usually, the presenting problem(s) is of moderate to high severity. Physicians typically spend 60 minutes face-to-face with the patient and/or family.

• 99245 — Office consultation for a new or established patient. This code requires a comprehensive history, comprehensive examination, and medical decision making of high complexity.

Usually, the presenting problem(s) is of moderate to high severity. Physicians typically spend 80 minutes face-to-face with the patient and/or family.

Marty Kotlar, DC, CHCC, CBCS, is  president of Target Coding. Target Coding, in conjunction with Foot Levelers, offers continuing-education seminars on CPT coding and compliant documentation. He can be reached at 800-270-7044, through his Web site at www.TargetCoding.com, or by e-mail at drkotlar@targetcoding.com.