CPT Code for Consultation

CPT code for Consultation is of two types and this code selected based on the place where the service provided.

  1. Outpatient – CPT code for Consultation (New/Established Patient)
  2. Inpatient – CPT code for Consultation (New/Established Patient)

Outpatient – CPT Code for Consultation is:

  • 99241
  • 99242
  • 99243
  • 99244
  • 99245

Inpatient – CPT Code for Consultation is:

  • 99251
  • 99252
  • 99253
  • 99254
  • 99255

By the word consultation on documentation, don’t select the CPT code for consultation for the service rendered.

When to select the CPT Code for Consultation?

When Physician/PCP, request or referral to the other physician for opinion/determine regarding the care or condition of the patient. The other physician renders the treatment based on the request/referral from other physician. In this case the service rendered by the physician has to report the claim from CPT Code for consultation.

This consultation should be initiated by physician or appropriate source such as physician assistant, nurse practitioner, PT, OT, psychologist, insurance company, lawyer, pathologist, chiropractic doctors, then only the service rendered physician can report the claim from CPT Code for consultation.

If the patient and/or family member initiate the consultation by themselves, then it is not reported using the CPT code for consultation. It should be reported with appropriate other E & M codes based on the place the service provided.

How to select the level of CPT code for Consultation?

Before getting in to selecting the level of E & M – CPT code for consultation, first let us understand the 3 key components of E & M service.

3 Key components are:

  1. History
  2. Physical Exam
  3. Medical Decision Making

History key component levels are as follows

  • Problem Focus
  • Extended Problem Focus
  • Detailed
  • Comprehensive

Physical Exam key component levels are as follows

  • Problem Focus
  • Extended Problem Focus
  • Detailed
  • Comprehensive

Medical Decision Making key component levels are as follows

  • Straight Forward
  • Low Complexity
  • Moderate Complexity
  • High Complexity

Now let us see with examples to understand on how to select the appropriate level of CPT code for consultation.

Assume the patient arrives at doctor office for consultation after referring from other physician.

After reviewing the documentation, assume the following key components are reported.

Example 1:

History: Expanded Problem Focus EPF)

Physical Exam: Expanded Problem Focus (EPF)

Medical Decision Making: Straight Forward (SF)

EPF: 99242

EPF: 99242

SF: 99241/99242

In the above case all 3 key components are meeting, hence we can code the CPT code for consultation with 99242.

Suppose if all the 3 key components are not meeting or if it is not at the same level, then how to select the appropriate level of CPT code for consultation.

Example 2:

History: Problem Focused (PF)

Physical Exam: Expanded Problem Focus (EPF)

Medical Decision Making: Low Complexity (LC)

PF: 99241

EPF: 99242

LC: 99243

In this case we need to select the lowest one that is 99241. It means when 3 key components are not at the same level, then we need to code with lowest level of CPT code for consultation.

Example 3:

History: Detailed History (DH)

Physical Exam: Detailed Examination (DE)

Medical Decision Making: Moderate Complexity (MC)

DH: 99243

DE: 99243

MC: 99244

Here two are matching, but still we code with the lowest level of CPT code for consultation that is 99243.

Important Note:
  • Same way if the services provided are Inpatient consultation, we need to choose the appropriate level from the inpatient CPT code for consultation (99251 to 99255).
  • Medicare will not pay the consultation CPT codes.

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