General Surgery Coding Alert

Use this key modifier for clean claims.

When your surgeons perform office and outpatient consultations next year, you’ll need to incorporate some CPT^® 2023 changes if you want to get all the pay you deserve.

Good news: Because you’re already familiar with the 2021 E/M changes for office and outpatient coding, you won’t be totally surprised by the similar changes for consultation coding.

Read on to learn about updates to the guidelines and the code descriptors that will alter how you code office/outpatient consultations next year.

See What’s New in Consultation Section Guidelines

When deciding who can use the office/outpatient consultation codes, you’ll find some new direction in the 2023 guidelines. While the current guidelines define the consultant as a “physician,” the 2023 update broadens the definition to “physician or other qualified health care professional.” Adding other professionals as a consultant definition also extends who “may initiate diagnostic and/or therapeutic services” at the visit.

POS: The outpatient consultation guidelines for 2023 also change what counts as the place of service (POS) for the consultation codes. Here are the revisions you’ll see in the calendar year (CY) 2023 update compared to the 2022 guidelines:

CY 2022: “…report consultations provided in the office or in an outpatient or other ambulatory facility, including hospital observation services, home services, domiciliary, rest home, or emergency department.”

CY 2023: “…report consultations that are provided in the office or other outpatient site, including the home or residence, or emergency department.”

Mandatory modifier: As in 2022, the guidelines in 2023 state that you should append modifier 32 (Mandated services) to a consultation that a third party mandates. For example, if a payer requests a consultation for a second opinion before approving treatment, you should append modifier 32 to the applicable consultation code.

Choose the Correct Consultation Code via Time or MDM

The biggest change to the outpatient consultation codes in 2023 is that you may now choose the code based on time or medical decision making (MDM) level, just as you learned to do with the outpatient E/M codes in 2021.

“As part of the 2023 revisions, this range of consultation codes can be documented through either time or MDM. History and exam, as with office visits, are no longer key components of consultations,” says Nancy Clark, CPC, COC, CPB, CPMA,CPC-I, COPC, AAPC Fellow, senior manager at Eisner Advisory Group LLC in Iselin, New Jersey.

Beginning on Jan. 1, 2023, you’ll use either documented time or MDM to support your E/M consultation code choice. You should review your individual payer preferences, but as long as they don’t have specific additional requirements, you, along with provider documenters, can decide how to support your code choice for the encounter. Provider documenters are the individuals who document and select the code.

What if you have a report that states the provider used a certain level of MDM, but the total time surpassed a higher level of MDM? “If the provider documents cumulative time along with the MDM and relevant history/physical examination, the coder can select the method that benefits the provider,” says Carol Pohlig, BSN, RN, CPC, manager of coding and education in the department of medicine at the Hospital of the University of Pennsylvania in Philadelphia.

The same applies to provider documenters. The provider has the ultimate responsibility to document and select the code. “If the provider believes the encounter was especially lengthy, they may choose to document the time spent in various activities and select a code based on time,” Clark adds.

Focus on Revised Office/Outpatient Consultation Codes

In addition to guideline changes, you’ll find updated office/ outpatient consultation code definitions in CPT^® 2023 that allow the provider to select the level of the visit based on MDM or time, when applicable.

Delete: CPT^® 2023 deletes 99241 (Office consultation for a new or established patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making). Instead, you should report 99242 for a consultation that involves straightforward MDM.

Beyond the deletion, you’ll find that CPT^® 2023 revises the rest of the office/outpatient consultation E/M codes as follows. Note: Portions of the revised descriptors are emphasized for easy reference:

• 99242 (Office or other outpatient consultation for a new or established patient, which requires a medically appropriate history and/or examination and straight­forward medical decision making. When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded.)
• 99243 (Office or other outpatient consultation for a new or established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded.)
• 99244 (Office or other outpatient consultation for a new or established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded.)
• 99245 (Office or other outpatient consultation for a new or established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 55 minutes must be met or exceeded.)

Time: Now that the codes allow you to bill by time, what if your surgeon documents spending more than 55 minutes in the office consultation visit? The answer lies with the note following 99245 that sates “for services 70 minutes or longer, use prolonged services code +99417”

In other words, you can now use the add-on code +99417 (Prolonged outpatient evaluation and management service(s) time with or without direct patient contact beyond the required time of the primary service when the primary service level has been selected using total time, each 15 minutes of total time (List separately in addition to the code of the outpatient Evaluation and Management service)) for outpatient consultation services lasting 70 minutes or longer.

Do this: If you’re billing an E/M visit solely on the basis of time, you can assign +99417 only after 15 minutes have elapsed beyond the minimum time required for the highest-level primary service.

In the cases of office/outpatient consultations, you cannot assign +99417 until 15 minutes have passed after the initial 55 minutes of the 99245 consultation — in other words, 70 minutes total. Additionally, the 15 minutes of +99417 may count even if the provider was not in direct contact with the patient.

Tip: Keep in mind that while not all payers accept consultation codes, those who do may have different rules regarding coding and counting time for prolonged services. Be sure to review and apply the relevant payer policies. For instance, Medicare may decide to use different time limits and prolonged-service code G2212 (Prolonged office or other outpatient evaluation and management service(s) beyond the maximum required time of the primary procedure which has been selected using total time on the date of the primary service …) before the new codes go into effect. Stay tuned for updates on Medicare rules for these new consultation codes.

Resource: For the full list of 2023 E/M code and guideline revisions, go to www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf.