Wiki Outpatient consultations

[REGINALD068]

Good morning
This is my first time in the Forum, so please accept my apologies if I'm not using the proper guidelines, if there are any. My question is regarding how to select the correct outpatient consultation code. Do I follow the same guidelines as I would in selecting the proper level E/M? Do consults require a certain number of elements for ROS, PFSH, Body areas/organ systems to review? I know it's time based, but what else is there? I've researched this topic and come up with NOTHING!!! Help!!

 

[Pathos]

Hello and welcome to the forum REGINALD068!

Per AMA CPT book, Consultations follow similar E/M guidelines as New Patients when it comes to History, Exam and Medical Decision Making components. In fact, they are identical to each level (Consult level 3 = New Patient level 3 in terms of E/M required components ONLY). The time thresholds for each Consult E/M level are greater than New Patient visits as well (don't forget the "Greater than 50% of XX minutes + brief summary" statement too):

99241 - 15 minutes
99242 - 30 minutes
99243 - 40 minutes
99244 - 60 minutes
99245 - 80 minutes

Note that not all insurances (Medicare being a big one) currently do NOT accept consultations and some allow you to crosswalk the code to a New Patient instead. There are also some consultation requirements, but may vary from payer to payer. Some common guidelines/requirements:

1) A referral from the referring provider in the patient's chart somewhere.
2) An outgoing letter to the referring provider or Carbon Copying the provider in your EHR.
3) Some notation in the documentation acknowledging the consult (this might be just out of courtesy, may not be a requirement for all insurances).

This should be a start, however I would double check the patient's payer consultation policies to ensure clean claims.

Good luck!

 

[REGINALD068]

Thank you so much for your assistance. I'm aware Medicare no longer acknowledges consults. Does the Provider have to state, within the documentation, how long he spent with the patient?

 

[Pathos]

You're welcome!

Unless the provider is performing a service where time is a required component, the provider does not have to document time unless he/she follows time documentation requirements (Greater than 50%...etc.).

So in short: For a regular Consultation visit, time is not a required component.

 

[tadapoof]

I'm in a family practice setting that also has a behavioral health outpatient program. If I have a provider who requests a consult about a patients bipolar disorder and meds, does the BH provider actually have to see the patient or is review of the patient's chart and medical history enough (as long as there is proper documentation to support time spent in the chart and formulating the opinion) enough to use the 99242 code?