When Does Your Advice Qualify as a Consultation:
Getting Paid for Consultation Codes
Published on Fri May 01, 1998
A primary physician calls your ob/gyn clinic and requests that a perimenopausal patient with irregular menses and menopausal symptoms be seen by one of your gynecologists. When is it appropriate to use the E/M codes in the category of Consultations (99241-99275)? Because consultations generally pay more than new patient office visits, you will want to use them whenever appropriate, but you should also use them correctly to avoid problems in the event of an audit.
The CPT defines a consultation as 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. To qualify for reimbursement for this service, the medical record must include three important elements: Reason, Request and Reply.
Receiving a written request and reason for a consultation would be ideal, but typically, such requests come in the form of a phone call. In fact, practice managers report that these requests often become known only when the patient calls for an appointment. Therefore, it is imperative that you make sure: (1) the request is truly from the physician, (2) that the medical record specifically documents the person asking for the consult, and (3) that the opinion or advice is requested for a specific reason. If a written request is provided, of course, it should be included in the medical record. Once the consultation is complete, a reply should be sent to the referring physician. Be sure to document this was done and how your consult was transmitted to the referring physician. Even though some physicians relay their opinions by phone and document this in the record, an audit may consider this evidence insufficient unless a copy of the written report also appears in the chart.
When a patient or family (instead of a physician) requests an opinion or advice, this should be noted in the medical record. Be careful -- these kind of consultations should be coded with the Confirmatory Consultation codes (99271-99275) only. If a third party payer (or government or school for mandatory physicals, or police agencies in cases such as abuse or rape) requires the consultation, then use 99271-99275 plus the 32 modifier (Mandated Services) or the five-digit modifier 09932 should be used.
Tip: Remember, all consultations are requests for advice or opinion only. A request for the performance of a specific procedure is not a consultation, and the appropriate new or established patient codes should be used. However, a consulting physician has the option during an initial consultation visit to initiate diagnostic and/or therapeutic services. If this is done, then the consultation should be coded appropriately, and the procedure should be identified separately using the appropriate CPT code. [...]
