Consultation Codes

Consultations(99241-99245) can be performed in the office or outpatient setting,or in the hospital.Consults may be performed for an established or new patient as long as the criteria for the consultation codes are met. To support a consultation code, the physician consultant must be asked for his or her opinion and advice regarding a specific problem by another physician or appropriate source, the definition of which may be a nurse practitioner, a physician assistant or another colleague. The request is either 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. The written or verbal request may be made by a physician or other appropriate source and documented in the patient’s medical record by either the consulting or requesting physician or the appropriate source. The consultant physician may initiate diagnostic or therapeutic services at the same or a subsequent visit. The request for consultation must be documented in the patient’s chart along with a report of the consultant’s findings. The consultant physician then must communicate the findings to the physician or other appropriate source, either by documentation in a shared chart or by a written report to the requesting physician or other appropriate source. The history, exam and medical decision-making levels have the same requirements as those for a new patient.

Beginning in 2010, Medicare discontinued payment for consultation codes. The Federal Register indicates the consultation codes 99241-99255 are invalid for Medicare by using the status code “I” on the Physician RVU Fee Schedule. This guideline is specific to Medicare but may be adopted by other payers in the future. United Healthcare already has indicated it will not recognize consultation codes for their Medicare Advantage programs. All allergy practices should check with their third-party payers to see if the consultations codes are still recognized as appropriate codes for the plan’s beneficiaries. In place of consultation codes, physicians are to use new patient or established patient codes for services performed in their offices or other outpatient facilities. Physicians also need to follow the guidelines appropriate for the new or established patient codes as published in the CPT book.

Inpatient services for Medicare patients and other patients whose plans do not recognize consultation will be coded differently. If a physician is asked to see a patient in the hospital as a consultant, the consulting physician will use the initial patient encounter codes (99221-99223). If you are the admitting physician and not the consulting physician, you will use the same codes (99221-99223), and in addition, you will need to indicate with the use of a modifier that you are the admitting physician. The modifier to indicate physician ofrecord or admitting physician isAI.After the initial encounter with the patient, physicians will continue to use the subsequent care codes for hospitalized patients (99231-99233) as appropriate to the medical care provided to the patient.

Prolonged Services with Direct Patient Contact Codes  

Prolonged services codes (99354-99357) are for those services when a physician or other healthcare provider is in direct patient contact providing care that is beyond the usual service in either the inpatient or outpatient settings (Table 6.1). Direct patient contact includes any additional non-face-to-face time exclusive of the patient’s direct care. The direct patient contact services are provided in addition to a designated E/M service provided on the same calendar day. Either code 99354 or code 99356 is used to report the first hour of prolonged service on a given date, depending on the place of service. These codes should be used only once on a specific day. The time may be provided continuous or interval through the calendar date. Prolonged services of <30 minutes are included in the base E/M code.

CODES FOR PROLONGED SERVICES WITH FACE-TO-FACE TIME 

Total duration of prolonged services                           Code

<30 min                                           Included in the base E/M code

30-74 min                                                                    99354

75-104 min                                                      99354, 99355 × 1

105-134 min                                                    99354, 99355 × 2