CPT code for Consultation is of two types and this code selected based on the place where the service provided.
By the word consultation on documentation, don’t select the CPT code for consultation for the service rendered.
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.
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:
History key component levels are as follows
Physical Exam key component levels are as follows
Medical Decision Making key component levels are as follows
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.
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