General Surgery Coding Alert

Question: Can physicians of the same specialty request or receive a consult from other physicians of the same specialty? For instance, if general surgeon -A- requests a consult from general surgeon -B,- can general surgeon -B- bill the service as a consult?


Utah Subscriber


Answer: Yes, physicians of the same specialty can request and receive consultations (99241-99245 outpatient, or 99251-99255 inpatient) from one another. A Medicare-produced Medlearn Matters article (MM4215) clarified that a physician can provide a consultation for another physician of the same specialty. The service must meet two minimum conditions, however:

1. Documentation must verify all elements of a consultation service, including a request for consult in both the requesting and consulting physician's record, a reason for the consult request, and a written report from the consultant to the requesting physician outlining the consultant's findings and recommendations.

2. The consulting physician's knowledge and expertise must go above and beyond that of the requesting physician. In other words, the physician in the group being asked for the consultation must clearly have a skill set that the requester does not have. The chart must reflect the reason and justification for the consult.

Be aware, however, that the same practice cannot report two inpatient consultations for the same patient during the same hospital stay.

For instance, if a general surgeon admits the patient and consults with a partner who has more experience in that specialty, the partner can bill a consult (although you may have trouble getting paid for both doctors on the same day).

But if surgeon A provides an inpatient consult for another physician, and then requests a consult from surgeon B in the same practice who has more experience, you may not report the second visit as a consultation.