Wiki HELP!! Consult Codes


Jacksonville, FL
Best answers
If you do not have the formal consult request (99251-99255), do you down code to 99221 -99223, etc or do you downcode to the subsequent visit 99231 -99233 etc?

Also, this is for non medicare insurance**
I know for Medicare patient's we only use code 99221-99223.
I'm not sure what you mean by "formal consult request" but per CPT guidelines, this request may be verbal. It must be made by "a physician or other appropriate source" and the "request must be documented in the record by the consulting or requesting physician or appropriate source" (AMA CPT Professional 2012, page 18). If the physician in his/her consult report mentions the requesting provider, or thanks them for their request, this should fulfill this requirement.

That said, if there is no consult written report or if there is any real doubt as to whether this is a consult, you can't bill the consult codes. You can use 99221-99223, only if the patient is new (>3 years) to the consulting physician. Otherwise you must use the subsequent care codes 99231-99233.

Hope this helps!