Oncology & Hematology Coding Alert

Question: Is there a difference between an office consultation and an inpatient consultation? When should we use each code set?

Pennsylvania Subscriber

Answer: Keeping in mind that Medicare stopped paying for consultations in 2010, you would use the codes depending on the patient’s hospital status at the time of the consultation if your non-Medicare payer covers the service.

According to CPT^® 2019, you should report inpatient consults when “an inpatient consultation is performed on a date that the patient is admitted to a hospital or nursing facility.” You would report inpatient consults with codes from 99251 (Inpatient 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) through 99255 (… A comprehensive history; A comprehensive examination; and Medical decision making of high complexity …), depending on encounter specifics. The request for consultation should be documented in writing by the requesting healthcare professional.

Remember: You’ll use the inpatient consult codes for “all evaluation and management services provided by the consultant related to the admission,” according to CPT^® 2019.

If, however, the consult occurs before “a patient is admitted following an outpatient consultation (office, emergency department, etc.), and the patient is not seen on the unit on the date of admission,” you’d report the office consult codes, according to CPT^® 2019.

You would report office consult services with codes from 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.) through 99245 (A comprehensive history; A comprehensive examination; and Medical decision making of high complexity), depending on encounter specifics. The request for consultation may be documented either by the consultant or the requesting healthcare professional.

Important: For the Medicare patient, any outpatient consultation is billed as a regular outpatient visit (i.e, 99201-99215). Inpatient consultations would be reported with the appropriate initial hospital care code (99221-99223) for the initial evaluation or a subsequent hospital care code (99231-99233) for subsequent consultation visits. See the Medicare Claims Processing Manual, Chapter 12, Section 30.6.9.1 for more information.