It is not uncommon for doctors to have questions about billing consultation codes. Many physicians stopped coding consultation codes when Medicare decided not to pay for the codes. Consultation codes can still be billed by other insurance carriers. This article describes how to bill them and be paid more than the traditional office visits.
Three essential considerations regarding medical office visit consultation codes.
- Define Consultation. You must understand the definition and the documentation requirements of a consultation for medical office visits. If you are a clinician, you can bill consultation codes. This visit pays more than the corresponding outpatient and inpatient codes. According to the CPT book published by the American Medical Association, consultation codes are billing codes where a physician or clinician is requesting opinion or advice regarding management of a specific problem or condition. The consultation requirements state, this request for advice can be documented in the requesting physician’s chart or in the consultation physician’s chart. It is important that the request has been made. The consultation physician has to send written communication back to the requesting clinician.
A patient or family member cannot request a consultation. When the patient requests a visit with a physician to get their opinion or advice, it is called a office visit or second opinion. The CPT codes for outpatient visits are 99241-99245. The CPT Codes for inpatient consultations are 99251-99255.Only a physician or other qualified clinician can determine the medical necessity or a consultation.There are several patient conditions that may warrant the highest office consultation level in medical billing. If a patient has a condition of a detached retina, and another clinician is asking the ophthalmologist who can perform the surgery when and where it should be done. The retinal surgeon can bill the highest level consultation code, if his or her documentation shows a comprehensive medical history, a comprehensive eye examination and a medical decision making complexity of high complexity.
If a hospitalized patient falls and the patient’s condition is a subdural hematoma, the attending physician may request an inpatient advice and opinion on how to manage and treat the condition. The medical record must show that a consultation was requested. If the insurance company allows the medical billing of a consultation the codes, the inpatient codes of 99251-99255 should be submitted on the medical claim. Only the initial hospital visit can be billed as a consultation. The follow-up hospital visits must be billed using the subsequent hospital follow-up visit codes. Those codes are 99231-99233. - Document Request. You must make sure the referring source is asking your advice or or opinion in order to take care of the patient. It is not appropriate to bill a consultation code when the requesting clinician is asking you to take over care of the patient. This can occur in the inpatient or the outpatient setting.An example of a transfer of care location is in the Emergency Department. The emergency room physician is asking your opinion however he or she cannot continue to care for the patient after discharge. This results in transfer or care even though your opinion and treatment regimen was given.You cannot bill a consultation code in the emergency room.
There are specific codes to use for an emergency room evaluation. If the emergency department physician requests you see a patient with a metallic foreign body on his left eye and you remove it, the patient belongs to you not the emergency department physician. He has no reason to contact the emergency room physician unless he has a new problem. - Insurance Company Rules. You must know the insurance company that the patient has to know if they will allow you to bill the consultation code even if you treatment service follows the definition of a consultation request. This is true for both then inpatient and outpatient consultation codes.You cannot bill a consultation code if the patient has Medicare. Eliminating the consultation codes essentially caused a decrease in reimbursement for consulting physicians. When Medicare implemented this change in 2010 they increased the RVU value of Evaluation and Management Codes.
United Health Care in Texas as of June 2019 no longer accepts consultation codes. If an opinion or advice is requested either new patient or established patient office visit codes must be used in the outpatient setting or initial hospital visit codes must be used for the initial evaluation and subsequent hospital codes must be used in the hospital. Now other commercial insurances are trying to figure out ways to pay clinicians less.
When these payers do not recognize consultation codes, it is a way to reduce the payment to physicians.Finally, you must document effectively if your consultation code has to be changed to a corresponding outpatient evaluation and management code or inpatient hospital code. If you submit a consultation code of the insurance claim and the insurance company rejects the claim, your biller or practice manager will need to choose a different code. In the outpatient setting, it can be a new or established patient code and in the hospital it is a new initial hospital code. Each of these codes have specific history and physical examination requirements. It is better to obtain and document a comprehensive medical history and perform and document a comprehensive examination in order to be paid for your work.
It is not uncommon for doctors to have questions about billing consultation codes?
Why does any of this matter?
If you choose higher paying medical codes like consultation codes you will get paid more for your work.
For more information on how to maximize your clinical revenue by medical billing and coding, get the book Medical Coding Decoded: A Simple Guide to Applying Medical Codes in Your Practice at www.medicalcodingdecoded101.com.