ED Coding and Reimbursement Alert

Question: Should I use consultation codes (99241-99245) when a family physician sends a patient to the ED for evaluation of a specific complaint? If you read the CPT notes preceding the codes in the 2002 manual, it specifically states that the ED is one of the sites where consultations may be provided.

Iowa Subscriber  
Answer: Although consultations may be provided in the ED, documentation must support all the guidelines that govern them. A consultation is defined as a request for a medical opinion or advice about a specific condition, and is characterized by three clearly defined activities:

  The originating physician must formally request the consultation
  The consultant must review the patients condition
  The consultant must send a written report with findings to the requesting physician.
 
Typically, the physician does not immediately take over the care of the patient, although this may occur after the initial consultation is completed. If care is transferred, the request becomes a referral and is no longer coded or billed as a consultation.
 
ED physicians do not typically find themselves in the role of providing consultations as defined above, so these codes should be used with extreme caution.