Ophthalmology and Optometry Coding Alert

Question: Can we still use "consult" E/M codes?

North Carolina Subscriber

Answer:  The answer to that question depends on the payer. If your insurer accepts the codes, then yes, you can continue to use E/M consultation codes.

Starting in 2010, Medicare discontinued recognition of the consultation codes 99241-99245 (Office or other outpatient consultation ...) and 99251-99255 (Initial inpatient consultation services ...). Some payers continue to accept these codes, however, and CPT® maintained the codes in 2011 and again in 2012.

Opportunity: You shouldn't stop using the consultation codes if your payer accepts them. The codes pay 40 percent more than other E/M codes that have comparable levels of history, physical exam, and medical decision-making. The key is to be sure the use of consultation codes meet the definition of what a consultation is all about. Just using them when a patient is new and referred to your practice does not meet the definition. In fact, there are few instances when it is appropriate to assign consultation codes.

Know the difference: A consultation is supported when another provider requests your physician's opinion, advice, or recommendations following the evaluation of their patient. It is not used when another provider asks your doctor to manage the patients care. The intent is for the requesting physician to receive your physician's opinion and recommendations and receive the patient back to provide that care. Although it is fine for the consulting physician to begin treatment, the patient would be transferred back to the original provider for the treatment to continue. Again, if the intent is for your physician to evaluate and treat that patient for the problem, it is not a consultation.

Do this for Medicare: For Medicare and insurers that do not reimburse for consultation codes, you should choose one of the following codes for an E/M service that would qualify as a consult, depending on outpatient or inpatient status:

• 99201-99205 -- Office or other outpatient visit for the evaluation and management of a new patient ...
• 99211-99215 -- Office or other outpatient visit for the evaluation and management of an established patient ...
• 99221-99223 -- Initial hospital care ...
• 99231-99233 -- Subsequent hospital care.