Reporting Consultations for Medicare

Medicare will not pay for consultation codes (except telehealth consultations), and requires that consultations services be billed with the most appropriate (non-consultation) E/M code for the service.
Note: Other non-Medicare payers may allow you to continue to report Consultation codes. Check with individual payers for guidelines.
Outpatient consultations for Medicare Beneficiaries should be reported by selecting the appropriate level code from the Office or Other Outpatient Services (99201–99215).
Report inpatient consultations using the Initial Hospital Care code (99221–99223) for the initial evaluation and a Subsequent Hospital Care code (99231–99233) for subsequent visits.
In some cases, the service the physician provides may not meet the documentation requirements for the lowest level initial hospital visit (99221). According to CMS guidance found in MLN Matters® Number: SE1010 Revised, you may report subsequent hospital care codes (99231-99233) in these cases:

  1. How should providers bill for services that could be described by CPT inpatient consultation codes 99251 or 99252, the lowest two of five levels of the inpatient consultation CPT codes, when the minimum key component work and/or medical necessity requirements for the initial hospital care codes 99221 through 99223 are not met?
  2. There is not an exact match of the code descriptors of the low-level inpatient consultation CPT codes to those of the initial hospital care CPT codes. For example, one element of inpatient consultation CPT codes 99251 and 99252, respectively, requires “a problem focused history” and “an expanded problem focused history.” In contrast, initial hospital care CPT code 99221 requires “a detailed or comprehensive history.” Providers should consider the following two points in reporting these services. First, CMS reminds providers that CPT code 99221 may be reported for an E/M service if the requirements for billing that code, which are greater than CPT consultation codes 99251 and 99252, are met by the service furnished to the patient. Second, CMS notes that subsequent hospital care CPT codes 99231 and 99232, respectively, require “a problem focused interval history” and “an expanded problem focused interval history” and could potentially meet the component work and medical necessity requirements to be reported for an E/M service that could be described by CPT consultation code 99251 or 99252.

The same article assures providers that Medicare payers will pay for initial visits reported using subsequent care codes:

  1. How will Medicare contractors handle claims for subsequent hospital care CPT codes that report the provider’s first E/M service furnished to a patient during the hospital stay?
  2. While CMS expects that the CPT code reported accurately reflects the service provided, CMS has instructed Medicare contractors to not find fault with providers who report a subsequent hospital care CPT code in cases where the medical record appropriately demonstrates that the work and medical necessity requirements are met for reporting a subsequent hospital care code (under the level selected), even though the reported code is for the provider’s first E/M service to the inpatient during the hospital stay.

The physician who admitted the patient as a hospital inpatient (whether that physician is the “consultant” or another physician), should append modifier AI Principal physician of record to indicate that he or she is the admitting physician, and to distinguish the physician from others who may provide inpatient services.

John Verhovshek
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John Verhovshek, MA, CPC, is a contributing editor at AAPC. He has been covering medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University.

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