Neurology & Pain Management Coding Alert

Question: I-ve seen information containing consultation definitions that differ from CPT. How do I know which definitions to follow?

Oklahoma Subscriber

Answer: CPT states: "A consultation is a type of service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source. A physician consultant may initiate diagnostic and/or therapeutic services at the same or subsequent visit." And, as you-ve noted, some payers have slightly different interpretations of a consult.

CMS updated Medicare rules for consultations on Jan. 1, 2006. The AMA then clarified its opinion on what qualifies as a consultation in the 2007 CPT manual issued in late November 2006.

The 2007 CPT manual tried to clarify the AMA position as opposed to CMS- very stringent position.

You can download Medicare's updated consultation rules from the Medicare Carriers Manual, Chapter 12, section 30.6.10, at http://cms.hhs.gov/transmittals/downloads/R788CP.pdf (changes appear in red).

Bottom line: Apply the CMS rules for government payers, and apply the AMA rules for private payers.